INLAND VALLEY CARE AND REHABILITATION CENTER
For profit - Limited Liability company
221 Beds
Independent
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#1047 of 1155 in CA
Photo by Katherine Thomas
Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Inland Valley Care and Rehabilitation Center has received a Trust Grade of F, indicating poor performance with significant concerns. They rank #1047 out of 1155 nursing homes in California, placing them in the bottom half of facilities statewide, and #311 out of 369 in Los Angeles County, meaning there are only a few better options nearby. Although the facility is improving from 64 issues in 2024 to 60 in 2025, it still has a troubling record, with a total of 184 issues found, including critical incidents like failing to prevent a maggot infestation in a resident's ear and not notifying a physician about a resident's concerning health changes promptly. Staffing is somewhat stable with a 3 out of 5 rating and a turnover rate of 32%, which is below the state average, but the facility has incurred fines totaling $194,891, which is higher than 89% of California facilities, raising concerns about compliance. Additionally, while RN coverage is average, it is essential as registered nurses can identify issues that certified nursing assistants might overlook.
- Trust Score
- F
- In California
- #1047/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 32% turnover. Near California's 48% average. Typical for the industry.
- Penalties ○ Average
- $194,891 in fines. Higher than 51% of California facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for California. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 184 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 10%
Review needed
64 → 60 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 64 issues
2025: 60 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (32%)
16 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: 32%
14pts below California avg (46%)
Typical for the industry
Federal Fines: $194,891
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 184 deficiencies on record
2 life-threatening 4 actual harm
Sept 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide one of three sampled residents (Resident 14) or the Resident's Representative a copy of the Resident 14's medical record upon reque...
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Based on interview and record review, the facility failed to provide one of three sampled residents (Resident 14) or the Resident's Representative a copy of the Resident 14's medical record upon request and within two working days from notice per the facility's Policy and Procedure (P&P) titled, Residents Access to Records. This failure resulted in violation of Resident 14's rights and in Resident 14's Representatives not receiving the medical records in a timely manner. Findings: During a review of Resident 14's admission Record (AR), the AR indicated the facility admitted Resident 14 on 1/10/2025 with diagnoses that included lumbar region stenosis (narrowing of the spinal cannel which added pressure on the spinal cord and nerves) and hypertension (HTN, high blood pressure). During a review of Resident 14's Minimum Data Set (MDS, a resident assessment), dated 1/16/2025, the MDS indicated Resident 14's cognitive skills were intact. The MDS indicated Resident 14 required substantial assistance performing Activities of Daily Living (ADLs). The MDS indicated Resident 14 required substantial assistance turning from left to right in bed and transferring from the bed to chair or the chair to the bed. During a review of the Declaration of Custodian of Records (DCR), dated 6/13/2025, the DCR indicated record request date of 6/13/2025, addressed to medical records assistant in facility. During a review of Health Insurance Portability and Accountability Act (HIPPA, United States federal law enacted in 1996 that sets national standards for protecting sensitive patient health information, or Protected Health Information (PHI). It establishes rules for the secure and confidential handling, storage, and transmission of PHI to prevent unauthorized disclosure, and also addresses continuity of health insurance coverage and fraud reduction) Compliant Authorization for The Release of Patient Information dated 5/1/2025, the form indicated Resident 14 signed the authorization. During an interview on 9/11/2025 at 3:30 pm with Legal Assistant (LA), the LA stated, I have continued to request records from Point Click Care (PCC, a cloud based electronic health record platform designed for the skilled nursing facilities) format, but the facility continues to send uncomplete printed and scanned records. During a concurrent record review and interview on 9/15/2025 at 11:00 am with Director of Medical Records (DMR), the facility's policy and procedure (P&P) titled, Resident Access to Records, dated 12/14/2020 was reviewed. The P&P indicated Electronic Access-In an electronic form or format when such records are maintained electronically upon request Respond within twenty-four (24) hours for access, within forty-eight (48) hours for copies or provision in electronic format excluding weekends and holidays. The DMR stated the medical records department should have followed the P&P but they didn't.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one of three sampled resident (Resident 8) from medication ...
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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 three sampled resident (Resident 8) from medication administration error in accordance with prescriber orders as indicated in the facility's policy and procedure (P&P) titled, Administering Medications. This failure resulted in Resident 8 administered melatonin (a hormone supplement that signals the body that it's time to sleep) pills without a physician order. Findings:
During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (the final stage of chronic kidney disease (CKD) where the kidneys have permanently failed and can no longer function at a level needed to sustain life), and dependence on renal dialysis (a patient's lifelong reliance on the dialysis machine to filter waste from their blood, as their kidneys can no longer perform this function.)
During a review of Resident 8's History and Physical Examination (H&P), dated 8/25/2025, the H&P indicated Resident 8's has the capacity to understand and make decisions.
During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was intact, and independent in eating, oral hygiene, with partial to moderate assistance with toileting hygiene, lower body dressing, and putting on/taking off footwear.
During a review of Resident 8's Change in Condition Evaluation (CIC), dated 8/28/2025 at 11:48 pm, the CIC indicated Resident 8 was given four (4) tablets of Melatonin on 8/27/2025, physician notified, without order, continue to monitor, call MD for any change of condition.
During a review of Resident 8's Care Plan Report (CP), dated 8/28/2025, the CP indicated risk for possible adverse reaction from melatonin, goal will be free from adverse reaction, and interventions monitor for adverse reaction such as drowsiness, headache, vivid dreams – nightmare, dizziness or nausea, mood changes, stomach cramps, and notify MD promptly.
During a review of Resident 8's Resident Grievance/Complaint Procedures (RGCP), dated 8/28/2025, RGCP indicated date the incident occurred: 8/27/2025, Patient was given four pills of melatonin = 12 milligrams (a unit of weight or mass) without physician order by Licensed Vocational Nurse (LVN, a healthcare profession who provides basic nursing care to patients under the supervision of registered nurses (RNs) or physicians) 2. LVN 2 validated the administration of four tablets of melatonin to Resident 8 upon request and failed to check the order prior to administration.
During a review of Resident 8's Progress Notes (PN), dated 8/29/2025 at 11:22 am, the PN indicated Assessment done today due to four tablets of melatonin supplement taken.
During an interview on 9/15/2025 at 8:30 am with Resident 8, Resident 8 stated the night of 8/27/2025 LVN 2 gave me four melatonin tablets without a physician order.
During a concurrent interview and record review on 9/15/2025 at 10:00 am with Director of Nursing (DON, a licensed, experienced registered nurse who holds a senior leadership position within a healthcare facility, overseeing all aspects of nursing services and patient care), the facility's P&P titled Administering Medications, dated April 2019 was reviewed. The P&P indicated, Policy Statement, Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frame. DON stated we did not follow our facility P&P.
Aug 2025
27 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain written informed consent for one of five sampled residents (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain written informed consent for one of five sampled residents (Resident 7) for the use of Buspirone (an antianxiety medication use to treat anxiety [emotion characterized by feelings of tension, worried thoughts and physical changes]. This deficient practice had the potential to result in Resident 7 not receiving adequate or sufficient information regarding Buspirone to make an informed health care decision.Findings:During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included anxiety (emotion characterized by an unpleasant state of inner turmoil), depression (a feeling of severe sadness or hopelessness) and bipolar disorder (mental disorder with periods of depression and periods of elevated mood). During a review of Resident 7's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/5/2025 the MDS indicated Resident 7 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 7 needed maximum assistance (helper did more than half the effort and lifted or held trunk or limbs) to staff for lower body dressing. The MDS indicated Resident 7 needed moderate assistance (helper did less than half the effort) from staff for toileting hygiene, shower, upper body dressing and putting on/taking off footwear. During a review of Resident 7's Order Summary Report (OSR), dated 7/24/2025, the OSR indicated to administer Buspirone Hydrochloride (HCL) tablet 7.5 milligrams (mg) one tablet by mouth three (3) times a day for anxiety manifested by inability to physically rest/stay still causing distress. During a concurrent record review and interview on 8/19/2025 at 10:48 am with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated physician documentation of the Informed Consent for Resident 7's Buspirone used was not documented. LVN 4 stated the physician needed to inform Resident 7 to obtain informed consent for the use of any psychotropic medication. LVN 4 stated there was no other clinical documentation that consent was obtained for Resident 7 who received Buspirone. LVN 4 stated it was important to have an informed consent for residents receiving psychotropic medications and for the physician to discuss the risks and benefits and adverse effects (unwanted or undesirable effect) with Resident 7. During a concurrent interview on 8/19/2025 at 10:48 am with the Director of Nursing (DON) and record review of Resident 7's medical record (chart), the DON stated consent was not obtained prior to use of Buspirone. The DON stated it was important to have an informed consent for residents receiving psychotropic medications for the responsible party and residents to be aware of the risks and benefits and their needs to be discussed with residents or resident's responsible party by the physician. The DON stated psychotropic medications can have a harmful effect on the residents. During a record review of the facility's policy and procedure (P&P) titled, Psychoactive medication Informed Consent, dated 3/2024, the P&P indicated an informed consent for the specific medication will be obtained by the physician and verified by the nurse. The P&P indicated a signed consent form will be obtained as acknowledgement at the time of obtaining the informed consent by an ordering physician and/or mid-level practitioner. The P&P indicated a signed consent form will be obtained as acknowledgment at the time of verifying informed consent by the facility staff. If a signed consent cannot be obtained a telephone verification of the informed consent will be documented on the consent form by the facility staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one of one sampled residents' (Resident 11) doctor of Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one of one sampled residents' (Resident 11) doctor of Resident 11's complaint of burning when urinating on 8/19/2025. This failure resulted in Resident 1 continuing to feel burning pain when urinating on 8/20/2025. (Cross Reference F550 and F684) Findings:During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood).During a review of Resident 11's History and Physical (H&P), dated 6/7/2025, the H&P indicated, Resident 11 had the mental capacity to understand and make medical decisions.During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 8/5/2025, the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 11 was dependent (helper does all the effort) on staff for bathing, dressing, and toileting hygiene. During a review of Resident 11's care plan titled Risk for Impaired Urinary Elimination., dated 7/29/2025, the care plan indicated facility staff were to notify Resident 11's healthcare provider immediately if Resident 11 had any voiding (urinating) abnormalities.During an interview on 8/19/2025 at 1:35 PM with Resident 11, Resident 11 stated Resident 11 had been recently treated for a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). Resident 11 stated Resident 11 currently had another UTI because Resident 11 felt a burning pain when Resident 11 urinated. Resident 11 stated Resident 11 had told multiple nurses (unidentified) about Resident 11's burning pain with urination, but the unidentified nurses told Resident 11 that Resident 11 was fine.During an interview on 8/19/2025 at 2:00 PM with Licensed Vocational Nurse (LVN) 9, the surveyor informed LVN 9 that Resident 11 complained of feeling burning pain when Resident 11 urinated. LVN 9 stated LVN 9 would go and evaluate Resident 11.During an interview on 8/20/2025 at 10:06 AM with Resident 11, Resident 11 stated Resident 11 still felt burning pain when Resident 11 urinated. Resident 11 stated Resident 11 had complained to multiple staff (unidentified) about the pain on 8/19/2025 but that no one did anything about Resident 11's complaint.During an interview on 8/20/2025 at 10:09 AM with LVN 9, LVN 9 confirmed Resident 11 had complained to LVN 9 that Resident 11 experienced burning pain when Resident 11 urinated. LVN 9 stated LVN 9 did not notify Resident 11's doctor of Resident's complaint of burning when urinating. LVN 9 stated LVN 9 notified Registered Nurse (RN) 4 about Resident 11's complaint of burning when urinating.During an interview on 8/20/2025 at 10:15 PM with RN 4, RN 4 stated burning when urinating is a symptom of a UTI. RN 4 stated if a resident (in general) complained of burning when urinating, the staff should call the resident's (in general) doctor. RN 4 stated RN 4 did not notify Resident 11's doctor of Resident 11's complaint of feeling burning pain when urinating.During a concurrent interview and record review on 8/21/2025 at 9:06 AM with RN 1, Resident 1's lab report (LR) titled, Urinalysis, collected 8/20/2025 was reviewed. The LR indicated Resident 11's urine showed a large amount of Leukocyte esterase (an enzyme test that detects the presence of white blood cells [WBCs] or their enzymes in the urine, which often signals a UTI) and positive for nitrite (can indicate a bacterial UTI). RN 4 stated Resident 11's LR indicated Resident 11 had a UTI. During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status revised 11/2015, the P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The P&P indicated, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been.A significant change in the resident's physical/emotional/mental condition.A need to alter the resident's medical treatment significantly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to maintain a clean and stain-free floors of Resident 86's room and in Station 4 shower rooms.This failure resulted in an unsanit...
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Based on observation, interview and record review, the facility failed to maintain a clean and stain-free floors of Resident 86's room and in Station 4 shower rooms.This failure resulted in an unsanitary appearance and did not maintain a homelike environment for the residents. Findings:During a review of Resident 86's admission Record (AR), the AR indicated the facility admitted Resident 86 on 5/27/23 with diagnoses that included Type 2 diabetes mellitus (elevated blood sugar level) and acute kidney failure (kidneys are not able to filter waste).During a review of Resident 86's History & Physical (H&P) dated 5/30/25, the H&P indicated Resident 86 had the capacity to make medical decisions.During a review of Resident 86's Minimum Data Set (MDS, a resident assessment tool) dated 8/16/25, the MDS indicated Resident 86 was independent for shower/bathing self.During a concurrent observation and interview on 8/22/25, at 3:30 p.m., with the Maintenance Supervisor (MS), Resident 86's floor had black stains. The MS stated the MS and the MS's staff check each resident's room weekly and there was no log kept. The MS stated the black stains observed on Resident 86's floor were dirt. During a concurrent observation and interview with the MS, two Station 4 shower rooms were observed. A black colored substance was observed on the floor and grout of the showers. The MS stated it could be cleaner and there was no log kept. The MS stated it was important for the floor areas to be cleaned because it has to be like a house and their home.During a review of the facility's Policy and Procedure (P&P), titled, Quality of Life-Homelike Environment, revised May 2017, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a plan of care for one of one sampled resident (Resident 7),...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a plan of care for one of one sampled resident (Resident 7), who sustained a fall on 8/15/2025, as indicated in the facility's policy Care Plans, Comprehensive Person Centered. This deficient practice had the potential to place Resident 7 at risk for recurrent falls.Findings: During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included anxiety (emotion characterized by an unpleasant state of inner turmoil), depression (a feeling of severe sadness or hopelessness) and bipolar disorder (mental disorder with periods of depression and periods of elevated mood). During a review of Resident 7's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/5/2025, the MDS indicated Resident 7 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 7 needed maximum assistance (helper did more than half the effort and lifted or held trunk or limbs) to staff for lower body dressing. The MDS indicated Resident 7 needed moderate assistance (helper did less than half the effort) to staff for toileting hygiene, shower, upper body dressing and putting on/taking off footwear. During a review of Resident 7's Care Plan titled, Fall, initiated on 7/8/2025, the care plan did not indicate that Resident 7 had a fall on 8/15/2025. The care plan interventions indicated for nursing staff to keep the resident's bed in its lowest position and to place bilateral floor mats. During a review of Resident 7's Fall Risk Evaluation (FRE- method of assessing a patient's likelihood of falling), dated 8/15/2025, the FRE indicated Resident 7 was assessed as having had 3 or more falls in the past 3 months, had balance problem while standing, and while walking and required use of assistive devices and had a risk for falls. During a review of the interdisciplinary team (IDT) conference record dated 8/18/2025, the IDT record indicated Resident 7 had a syncopal (temporary loss of consciousness usually related to insufficient blood flow to the brain) episode and laid down on the floor. The IDT record indicated the interventions provided to Resident 7 for fall management were short term and long-term care plan for care plan for fall was updated. During an interview and concurrent record review on 8/19/2025 at 3:48 pm, with Licensed Vocational Nurse 5 (LVN 5) of Resident 7's medical records (PointClickCare - PCC, a cloud-based software used in long-term and post-acute care facilities and chart), LVN 5 stated Resident 7 had a fall on 8/15/2025 and the care plan for falls was not revised. LVN 5 stated Resident 7's CP for falls needed to be revised to determine if nursing interventions for the fall was effective or not. During an interview on 8/22/2025 at 9:52 am, with the facility Director of Nursing (ADON), the DON stated the care plan for falls needed to be revised to address nursing interventions for Resident 7 after a fall on 8/15/2025. The DON stated Resident's 7's care plan needed to be revised to determine if fall interventions were effective or not to prevent future falls. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person - Centered, revised 3/2022, the P&P indicated the assessment of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The P&P indicated the interdisciplinary team reviews and updates the care plan when there has been a significant change in the residents' condition, when the desired outcome is not met, when a resident has been readmitted to the facility from a hospital stay.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff members failed to provide peri-care (the cleaning and mai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff members failed to provide peri-care (the cleaning and maintenance of the perineum, the area between the anus and the genitals) for two of two sampled residents, (Resident 136 and Resident 27), who required physical assistance with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). This deficient practice had the potential to place Resident 136 and Resident 27 at risk for increased risk for infection, skin breakdown and further potential health complications.Findings:a). During a review of Resident 136's admission Record (AR), the AR indicated Resident 136 was admitted to the facility on [DATE] with diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD- is a common lung disease causing restricted airflow and breathing problems), type 2 diabetes (elevated sugar in the blood), pneumonia (is an infection that inflames the air sacs in one or both lungs), morbid obesity (a person's body has a lot of extra weight) with alveolar hypoventilation (is a breathing disorder that affects some people who have obesity). During a record review of Resident 136's History and Physical (H&P), dated 7/17/2025, the H&P indicated Resident 136 does has the capacity to understand and make decisions. During a review of Resident 136's Minimum Date Set (MDS - a resident assessment tool), dated 7/22/2025, indicated Resident 136 required dependent care (helper does all of the effort, the resident does none of the effort to complete the activity) from staff for toileting hygiene, shower/bathing self and putting on/taking off footwear. During a review of Resident 136's Skin Check (SC) dated 7/17/2025 at 2:49 PM, the SC indicated Resident 136 with a new skin issue the middle are of the sacrum (a triangular bone at the base of the lower back) that was present on admission considered a pressure ulcer/injury (damage to the skin caused by continuous pressure) Stage 3 full-thickness skin loss (a bedsore where the skin is destroyed and extending into deeper tissue and fat) and surrounding tissue to be fragile with skin that is at risk for breakdown. Additional care areas indicated incontinence management and mattress with pump. During a review of Resident 136's untitled Care Plan Report (CP) dated 7/17/2025, the CP indicated Resident has problems with Activities of Daily Living (ADL- referring to fundamental personal care tasks such as bathing, dressing, eating, transferring, toileting, and managing continence) decline by decline in functional mobility skills and potential for skin break down. The goal is to prevent skin breakdown but there are no ADL maintenance or repositioning included or documented in any other CP in Resident 136's medical record (MR). During a review of Resident 136's Wound Evaluation & Treatment Progress Note (WETPN) dated 8/14/2025, the WETPN indicated Resident 136's skin exam indicated the sacrococcyx (the tail bone located at the base of the spine), and sacral region (lower back) wound closed. The listed recommendations indicated aggressive offloading (refers to the practice of relieving or redistributing pressure from a specific area of a patient's body to prevent and treat wounds, especially pressure ulcers) recommended every two (2) hours turning; no sitting beyond two hours; frequent diaper checks and changes; Additional recommendations indicated to turn patient every two hours and to keep skin clean and dry.b). During a review of Resident 27's AR, the AR indicated Resident 27 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (a severe and irreversible condition where the kidneys have lost most of their function and can no longer adequately filter waste products from the blood), cutaneous abscess (a collection of pus under the skin) of the groin (the area between the abdomen and the thigh), laceration with foreign body of right buttock, necrotizing fasciitis (a bacterial infection that enters the body, most commonly through a break in the skin such as a cut, scrape, or burn), morbid (severe) obesity due to excess calories, type 2 diabetes (sugar in the blood) and inflammation of the vagina and vulva.During a review of Resident 27's untitled CP dated 7/23/2025, the CP indicated Potential for infection related to surgical incision on right groin extended to right buttock. Interventions indicated to keep area clean and dry.During a review of Resident 27's MDS dated [DATE], the MDS indicated Resident 27 required substantial/maximal assistance (helper does more than half the effort) from staff for toileting hygiene and upper body dressing. Resident 27 was dependent on staff assistance for shower/bathing self and putting on/taking off footwear and lower body dressing.During a record review of Resident 27's H&P, dated 8/17/2025, the H&P indicated Resident 27 does has the capacity to understand and make decisions.During a review of Resident 27's untitled CP dated 8/17/2025, the CP indicated Resident has problems with ADL decline, by a decline in functional mobility skills and potential for skin break down. The goal is to prevent skin breakdown but there was no ADL maintenance or repositioning included or documented in any other CP in Resident 27's MR.During initial observation and interview with Resident 27 on 8/19/2025 at 10:04 AM, Resident 27 was observed sitting at the side of the bed. Resident 27 stated, I want to get clean. When they do peri-care, I don't feel clean. The staff do it for me. I'm all dirty. It makes me feel mad and sad at the same time. I'm a very clean person; it makes me feel staff is not listening to me. During an initial observation and interview with Resident 136 on 8/19/2025 at 11:03 AM, Resident 136 was observed to be sitting up in bed watching television (TV). Resident 136 stated, I've had a bowel movement (BM) since 7:30 AM. I've been calling them all morning. It's 11:07 AM now and I'm still waiting. I'm afraid my wounds will come back. I am very upset and embarrassed. Sometimes I wait up to three (3) hours to get cleaned up. I call and they don't come. During an interview with License Vocational Nurse (LVN9) on 8/19/2025 at 11:11 AM, LVN9 stated Resident 136 should not have been waiting since 7:30 AM to be cleaned up by staff especially if Resident 136 had a bowel movement. LVN9 stated it was not sanitary, and it must be uncomfortable for Resident 136 to be soiled for such a long period of time. LVN9 stated she would go look for Certified Nursing Assistant (CNA4) to have Resident 136 cleaned up. LVN9 stated that CNA4 was assigned to Resident 136 but CNA4 was busy with another resident and that CNA4 would clean up Resident 136 when there was a chance. During an interview with CNA4 on 8/19/2025 at 11:14 AM, CNA4 stated there were 10 residents on his assignment for the day and someone might have answered the call light earlier and not communicated to CNA4 that Resident 136 was soiled. CNA4 stated he was busy earlier because there was a room change. CNA4 stated that the Cnas can feel overworked and burned out at times and feel like they don't have time to change all the residents in their assignments in a timely manner. During a concurrent interview with CNA4 on 8/20/2025 at 11:39 AM, CNA4 stated, I do find some of the alert residents that have been waiting for a long period of time tell me the previous shift staff answered the call light but never provided the care they were requesting. Sometimes when I check a resident to clean them up, they are very soiled. They have gone urine or poo once or twice in the same diaper. Per CNA4, the LVNs or Charge Nurses (CN) are supposed to help, and they can also do the job. During a concurrent interview with Resident 27 on 8/20/2025 at 11:54 AM, Resident 27 stated that the day before, after dinner she had a BM and felt dirty, and her vaginal area was itchy. Resident 27 stated she asked the night shift Cna to clean her. Resident 27 stated that when the night shift Cna cleaned her vaginal area, the Cna showed Resident 27 the towel she used to clean her and showed Resident 27 that she still had poop in her vagina. Per Resident 27 the day shift cna (CNA4) had not cleaned her properly. During an interview with LVN10 on 8/20/2025 at 11:56 AM, LVN10 stated The residents should get showers and peri-care often for hygiene and to prevent infections or skin problems. It is not acceptable to have a resident sitting in their own filth for long periods of time. This can make them feel terrible, helpless, neglected, sad and depressed. Feeling this way puts them at risk for depression or anxiety withdrawal. During an interview with Infection Prevention Nurse (IPN) on 8/21/2025 at 3:10 PM, the IPN stated residents need to be provided with hygiene and peri-care as needed. The IPN stated that it's not acceptable to leave a resident for long periods of time if they are soiled. Per IPN, a resident that is left in soiled conditions for extended periods of time can have serious infection risks like skin tears, skin inflammation and bedsores. IPN stated, The combination of moisture and bacteria from urine and feces creates an environment that can quickly lead to skin breakdown, and other health complications. Also, it would make the resident feel uncomfortable, embarrassed and neglected, and their self-esteem would go down making them feel depressed. During an interview with the DON (DON) on 8/22/2025 at 9:10 AM, the DON stated that it is not acceptable for a resident to be in bed soiled for hours. The DON stated, As soon as a staff identify the resident needs to be changed, the resident still needs to be cleaned. Anyone can do it, including an LVN or RN. This is part of the supervision and mentoring the license nurses must provide to the cna. Per the DON if the resident does not receive proper ADLs including peri-care, the resident will be uncomfortable causing them discomfort and possibly suffering from irritating skin. During an interview with the Treatment Nurse (TN1) on 8/22/2025 at 1:33 PM, TN1 stated that ADLs and timely peri-care must be provided to all residents. TN1 stated that especially when residents are at risk of skin breakdown or have wounds it's extremely important to prevent infections. Per TN1, the main thing is to prevent infections and provide comfort. TN1 stated, It's not acceptable for a resident to be soiled and just have the resident sit there from 7 AM to 11:30 AM. The residents with wounds need to be repositioned as well. Even if the staff is busy, under no circumstances should the resident go for a long period of time without being changed. Per TN1, if a resident is left for long periods of time soiled or not being cleaned completely, it would make the resident feel uncomfortable, embarrassed and neglected. During a review of the facilities Policy and Procedures (P&Ps) titled, Activities of Daily Living (ADL), Supporting revised March 2018 indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During a review of the facilities P&P titled, Perineal Care, revised February 2018 indicated, The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin conditions. During a review of the facilities P&P titled, Residents Rights, revised December 2016 indicated Employees shall treat all residents with kindness, respect and dignity. During a review of the facilities P&P titled, Quality of Life-Dignity, revised February 2020 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example, promptly responding to a resident's request for toileting assistance.
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 ensure bilateral (both sides) hand rolls (a cylindric...
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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 bilateral (both sides) hand rolls (a cylindrical device used to support and position the hand) were maintained in correct position for one of one sampled resident (Resident 125).This failure had the potential for a decline in range of motion (ROM, measure of joint flexibility and functionality), stiffness, and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) for Resident 125. Findings:During a review of Resident 125's admission Record (AR), the AR indicated Resident 125 was admitted to the facility on [DATE] with diagnoses that included traumatic subarachnoid hemorrhage (a collection of blood that accumulates between the inner layer of the skull and the surface of the brain after a head injury), surgery on the nervous system (a complex network of organs, tissues, and cells that controls and coordinates all bodily functions), and benign prostatic hyperplasia (BPH, enlarged prostate gland).During a review of Resident 125's Minimum Data Set (MDS, a resident assessment tool), dated 7/29/2025, the MDS indicated Resident 125 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 125 was dependent (helper did all the effort) to staff with eating, oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene.During a review of Resident 125's Order Summary Report (OSR), dated 7/29/2025, the OSR indicated Resident 125 had an order for Restorative Nurse Assistant (RNA, a specialized role for certified nursing assistants that involves training in rehabilitation skills) to apply bilateral hand rolls for up to six (6) hours, five (5) times a week and for RNA to monitor skin integrity, pain and discomfort during or after splint (an external device used to support, protect, and immobilize an injured body part by preventing further damage and movement) application.During a concurrent observation inside Resident 125's room and interview on 8/19/2025 at 10:37 am with Licensed Vocational Nurse 1 (LVN 1), Resident 125 was awake, lying in bed with a hand roll on Resident 125's left hand. LVN 1 stated Resident 125's right hand roll was on the bed and not in Resident 125's right hand. LVN 1 stated the RNA should ensure the hand rolls were in place and kept in Resident 125's right hand throughout the duration of the treatment to provide effective treatment and prevent further contractures.During an interview on 8/20/2025 at 3:58 pm with RNA, the RNA stated residents on RNA services like hand rolls and/or splints should be monitored to ensure the hand rolls were properly applied and maintained throughout the duration of the application to prevent further contracture and decrease in mobility.During the interview on 8/21/2025 at 11:51 am with the Director of Nursing (DON), the DON stated the RNA should ensure splints and hand rolls were applied properly and kept in place throughout the duration of the application to prevent further contracture and decrease in range of motion.During a review of the facility's policy and procedures (P&P) titled, Resident Mobility and Range of Motion, revised July 2017, the P&P indicated, Resident with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.
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 Foley catheter (FC, a thin, flexible, rubber 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 Foley catheter (FC, a thin, flexible, rubber or plastic tube used to drain urine from the bladder) was secured on the resident's thigh in accordance with the facility's Policy and Procedure (P&P) Catheter Care, Urinary) for one of four sampled residents (Resident 131).This failure had the potential for Resident 131 to result in catheter-related complications.Findings:During a review of Resident 131's admission Record (AR), the AR indicated Resident 131 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body affecting the face, arm, or leg), acute kidney failure (a condition where the kidneys suddenly lose their ability to function properly) and urinary tract infection (UTI, an infection in the bladder/urinary tract).During a review of Resident 131's Order Summary Report (OSR), dated 8/9/2025, the OSR indicated Resident 131 had an order for a FC to gravity drainage every day shift.During a review of Resident 131's Minimum Data Set (MDS, a resident assessment tool), dated 8/12/2025, the MDS indicated Resident 131 had an intact cognition (ability to understand and process information). The MDS indicated Resident 131 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, required substantial/maximal assistance (helper did more than half the effort) from staff with toileting, upper and lower body dressing and dependent (helper did all the effort) from staff with shower.During a concurrent observation inside Resident 131's room and interview on 8/19/2025 at 9:38 am with Certified Nurse Assistant 1 (CNA 1), Resident 131 was in bed with FC hanging on the right metal frame of the bed. CNA 1 stated Resident 131's FC tubing did not have a securement device and was not secured on Resident 131's thigh. CNA 1 stated the FC tubing should be secured properly on the resident's thigh to prevent pulling during Resident 131's movement. During an interview on 8/21/2025 at 11:44 am with the Director of Nursing (DON), the DON stated all residents with indwelling catheters should have a securement device and tubing secured on the resident's thigh to hold the catheter in place and to prevent pulling and cause injury or trauma to the resident during mobility and transfers.During a review of the facility's Policy and Procedure (P&P) titled, Catheter Care, Urinary, revised August 2022, the P&P indicated, Ensure the catheter remains secured with a securement device to reduce friction and movement at the insertion site.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary care and services for a resident wi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary care and services for a resident with gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) for one of two sampled residents (Resident 75) by failing to:a. Ensure Resident 75's GT site dressing was changed consistently with the physician's order.b. Ensure an individualized and comprehensive GT site plan of care was developed for Resident 75.These failures had the potential for complications related to tube feedings for Resident 75.Findings:a. During a review of Resident 75's admission Record (AR), the AR indicated Resident 75 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure (a medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide between the body and the environment), dysphagia (difficulty swallowing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach).During a review of Resident 75's Order Summary Report (OSR), dated 2/9/2025, the OSR indicated Resident 75 had a treatment order for licensed staff to clean the mid-abdomen GT site with normal saline (NS), pat dry and cover with dry dressing daily, every day shift.During a review of Resident 75's Minimum Data Set (MDS, a resident assessment tool) dated 5/28/2025, the MDS indicated Resident 75 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 75 was dependent (helper did all the effort) to staff with eating, oral hygiene, toileting, shower, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 75 had a feeding tube for nutrition.During a review of Resident 75's Treatment Administration Record (TAR), dated August 2025, the TAR indicated Resident 75's GT site dressing treatment was not completed on 8/20/2025 and 8/21/2025.During a concurrent observation inside Resident 75's room and interview on 8/19/2025 at 10:03 am with Certified Nurse Assistant 1 (CNA 1), Resident 75 was in bed, and lying on Resident 75's back. CNA 1 stated Resident 75's GT site dressing was wet and soaked in yellow-colored liquid. CNA 1 stated CNA 1 did not know when the GT site dressing was changed.During an interview on 8/19/2025 at 10:37 am with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated GT site should be changed daily and as needed to keep the GT site clean and dry all the time to prevent skin irritation and skin breakdown and cause infection on the GT site.b. During a concurrent interview and record review of Resident 75's Care Plans on 8/20/2025 at 3:52 pm with Registered Nurse Supervisor 3 (RN 3), RN 3 stated Resident 75 did not have a care plan developed to address Resident 75's GT site care. RN 3 stated a care plan specific and centered on Resident 75's needs and treatment should have been developed to ensure necessary and appropriate interventions were provided for Resident 75.During an interview on 8/21/2025 at 11:48 am with the Director of Nursing (DON), the DON stated, the GT site needed to be kept clean, dry, covered, and secured to prevent skin irritation on the surrounding area around the GT site for infection prevention. The DON stated all residents with GT site should have a care plan to address the needs of the resident and assist and guide the staff on how to provide care and treatment to the residents with GT.During a review of the facility's policy and procedures (P&P) tiled, Gastrostomy/Jejunostomy Site Care, revised October 2011, the P&P indicated, To promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection. Review the residents' care plan and provide for any special needs of the resident. Assess the stoma site for signs of redness, pain or soreness, swelling or drainage. If the stoma has signs of irritation or infection, clean the area several times a day.During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person - Centered, revised 3/2022, the P&P indicated the comprehensive, person-centered care plan is develop within seven days of the completion of the required MDS assessment (Admission, Annual, or significant change in status), and no more than 21 days after admission.
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 interview and record review, the facility failed to manage urinary tract infection (UTI- bacteria enter the urinary tra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to manage urinary tract infection (UTI- bacteria enter the urinary tract) symptoms and urinary pain for one of four sampled residents (Resident 58).This deficient practice resulted in Resident 58 experiencing unrelieved pain which caused physical and emotional distress and did not maintain the resident's highest practical physical and mental well-being. (Cross Reference F684) Findings:During a review of Resident 58's admission Record (AR), the AR indicated Resident 58 was admitted to the facility on [DATE] with diagnoses that included pericardial effusion (buildup of fluid in the membrane that surrounds the heart), Type 2 diabetes mellitus (elevated blood sugar levels) with chronic kidney disease (kidneys unable to filter waste), and chronic obstructive pulmonary disease (blocked airflow making it difficult to breathe). During a review of Resident 58's Physician's Order (PO) dated 9/7/24, the PO indicated for licensed staff to administer Acetaminophen Oral Tablet 325 milligrams (mg-unit of measurement), 2 tablets by mouth, every four hours as needed for pain management, mild pain (1-3). During a review of Resident 58's PO dated 9/7/24, the PO indicated for licensed staff to administer Acetaminophen-Codeine Oral tablet 300-60 mg, one tablet by mouth, every four hours as needed for pain management for moderate to severe pain.During a review of Resident 58's History & Physical (H&P) dated 9/9/24, the H&P indicated Resident 58 had the capacity to make medical decisions.During a review of Resident 58's Physician Orders (PO) dated 11/10/24, the PO indicated pain assessment every shift: 0-No Pain, 1-3 mild pain,4-6 moderate pian, 7-10 severe pain.During a review of Resident 58's Minimum Data Set (MDS, a resident assessment tool) dated 6/6/25, the MDS indicated Resident 58 was cognitively intact (ability to understand and process thoughts), and required substantial/maximal assistance with toileting and personal hygiene.During a review of Resident 58's short term care plan dated 7/21/25 for pain when urinating, the CP indicated for nursing staff to notify Resident 58's physician (MD) of any changes.During a review of Resident 58's Progress Note (PN) dated 8/18/25 at 3:40 p.m., the PN indicated Resident 58 complained of dysuria (discomfort when urinating), was treated with antibiotics last month and will check the resident's urine again.During an interview on 8/20/25 at 8:34 a.m., Resident 58 stated Resident 58 had pain when urinating for three weeks. Resident 58 stated Resident 58 had taken two antibiotics but Resident 58 had no relief. Resident 58 stated Resident 58 told everybody in the facility that Resident 58 still had urinary pain, but the facility staff did not address her complaint of pain. During an interview on 8/20/25 at 3:45 p.m., Resident 58 stated Resident 58 had radiating 10/10 back pain when urinating, based on the pain scale (0= no pain, 10=worst pain). During a concurrent interview and record review on 8/20/25 at 4:30 p.m. with Licensed Vocational Nurse (LVN 3) of Resident 58's Progress Notes (PN) dated 8/18/25, the PN indicated Urine Analysis (UA) and Culture and Sensitivity (C&S- used to identify the specific bacteria causing infection). LVN 3 stated the UA and C&S were not carried out. LVN 3 stated licensed staff needed to check the physician (MD)/ Family Nurse Practitioner (FNP) Progress Note following a physician's assessment. During a review of Resident 58's Electronic Medical Record (EMR) with LVN 3, the EMR did not indicate a Situation, Background, Assessment, and Recommendation (SBAR- helps team share information) for Resident 58's complaint of dysuria noted in the MD progress note dated 8/18/25.During an interview on 8/20/25 at 4:38 p.m. with LVN 3, LVN 3 stated the FNP stated FNP forgot to tell the licensed staff to do UA with CS. During an interview on 8/20/25 at 5:00 p.m. with LVN 3, LVN 3 stated Certified Nurse Assistants (CNA) should communicate to licensed staff any foul smell or any complaints of pain reported by a resident to the licensed staff.During an interview on 8/20/25 at 5:20 p.m. at Resident's 58's bedside, Resident 58 stated Resident 58 had pain when urinating.During a phone interview on 8/22/25, at 8:55 a.m. with the FNP, the FNP stated the plan for a UA and CS was communicated to the nursing staff on 8/18/25 after FNP assessed Resident 58 but the FNP stated the FNP did not know the licensed nurse's name to whom the plan was communicated. The FNP stated the UA & CS for Resident 58 was missed. The FNP stated, the FNP would communicate orders verbally after resident assessments during on site to the nursing staff and a telephone order was written. The FNP stated Pyridium (a urinary analgesic that relieves pain) administration for pain upon urination was delayed. The FNP stated the FNP would refer residents to Urology (medical specialty that focuses on diagnosis and treatment of disorders related to the urinary tract system) but Resident 58 was not referred to Urology.During an interview on 8/22/25 at 10:34 a.m., with LVN 15, LVN 15 stated Resident 58 had a history of UTI. LVN 15 stated the care plan to address pain upon urination was not revised. LVN 15 stated the care plan was important because the care plan had interventions to manage the problem and track actions being taken to prevent further symptoms on the resident.During a review of the facility's Policy and Procedure (P&P), titled, Pain Assessment and Management, revised April 2018, the P&P indicated the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an informed consent (voluntary agreement to ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an informed consent (voluntary agreement to accept treatment and/or procedure after receiving education regarding the risks, benefits and alternatives offered) was obtained before the installation of bilateral (both sides) upper half siderails (adjustable metal or rigid plastic bars attached to the bed) for one of one sampled resident (Resident 8).This failure placed Resident 8 at risk for entrapment (an event in which a resident was caught, trapped, or entangled in the tight spaced around the bed) and injury from the use of siderails. Findings:During the review of Resident 8's admission Record (AR), the AR indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and osteoporosis (weak and brittle bones, due to lack of calcium and vitamin D).During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 7/26/2025, the MDS indicated Resident 8 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 8 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with eating, oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene.During a concurrent observation while inside Resident 8's room and interview on 8/19/2025 at 9:35 am with Certified Nurse Assistant 2 (CNA 2), Resident 8 was lying in bed, on Resident 8's back with upper half side rails up on both sides of the bed. CNA 2 stated Resident 8 had bilateral arms and hands contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). CNA 2 stated Resident 8 was dependent in all activities of daily living (ADLs) and did not have the ability to hold on to the side rails during positioning and bed mobility.During a concurrent interview and record review on 8/20/2025 at 10 am with Licensed Vocational Nurse 1 (LVN 1), Resident 8's OSR and medical record (chart) were reviewed. LVN 1 stated the OSR did not indicate Resident 8 had an order for bilateral upper half side rails use. LVN 1 stated there was no record that an informed consent was obtained before the installation of bilateral upper half side rails. LVN 1 stated side rails should not be installed without a doctor's order and a signed informed consent for the safety of the residents.During an interview on 8/21/2025 at 11:48 am with the Director of Nursing (DON), the DON stated all residents on side rail use need to have a doctor's order and a signed informed consent obtained before the installation of side rails to make sure that resident and/or responsible party were informed, and risks and benefits of side rail use were explained to prevent injury to the resident and restrict the resident's bed mobility.During a review of the facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, revised August 2022, the P&P indicated, The use of bed rails or side rails (including temporarily raising the side rails, for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.
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 observation, interview and record review, the facility failed ensure one of five sampled resident (Resident 34) was fre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed ensure one of five sampled resident (Resident 34) was free from unnecessary drugs as indicated in the facility's policy and procedure titled, Administering Medication. This deficient practice had the potential to result in unnecessary use of Tylenol (Acetaminophen, medicine that relieves mild to moderate pain and reduces fever). Findings:During a review of Resident 34's admission Record (AR), the AR indicated Resident 34 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure (condition characterized by a gradual loss of kidney function over time) and heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs).During a review of Resident 34's Order Summary Report (OSR), dated 6/30/2025, indicated to administer Tylenol Oral Tablet 325 milligrams (mg, unit of measurement), give two (2) tablet by mouth in the morning for pain. Give 30 minutes prior (before) to wound care, not to exceed (NTE) three (3) grams (gr, unit of measurement) in 24 hours. During a review of Resident 34's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/15/2025, the MDS indicated Resident 34 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 34 was dependent (helper does all of the effort) to staff for toileting hygiene and shower. The MDS indicated Resident 34 needed maximum assistance (helper did more than half the effort and lifted or held trunk or limbs) to staff for upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a medication pass observation on 8/21/2025 at 8:33 am, Licensed Vocational Nurse 8 (LVN 8) attempted to administer 2 tablets of Tylenol Oral Tablet 325 mg prior to wound care to Resident 34. During an interview on 8/21/2025 at 8:34 am, Resident 34 stated I don't have any wound. I don't want to take Tylenol.During an interview on 8/21/2025 at 9:30 am, with LVN 8, the LVN 8 stated, Tylenol was discontinued now (8/21/2022) because patient (resident) doesn't have any wound. Patient's wound was resolved.During an interview with the facility's Director of Nursing (DON) on 8/21/2025 at 10:08 am, the facility DON stated, Resident 34 did not need Tylenol Oral Tablet routinely because Resident 34's wound treatment was resolved. The DON stated Tylenol Oral Tablet was ordered to administer prior to wound care and Resident 34 did not have any wound. The facility DON stated it was unnecessary for Resident 34 to take Tylenol Oral Tablet for resident did not have wound or did not need wound treatment. During a concurrent review of Resident 34's Skin Observation Tool (SOT) dated 8/15/2025, and an interview with Registered Nurse 2 on 8/21/2025 at 2:05 pm, the SOT indicated Resident 34 was seen and evaluated by the wound consultant and had an order to discontinue treatment to the left anterior (front) lower leg wound. RN 2 stated the wound treatment was discontinued by the wound consultant on 8/15/2025. RN 2 stated Resident 34's wound was resolved.During a concurrent review of Resident 34's Medication Administration Record (MAR) dated from 8/1/2025 to 8/31/2025, and an interview with RN 2 on 8/21/2025 at 2:07 pm, the MAR indicated Resident 34 received Tylenol Oral tablet 325 mg, 2 tablets by mouth in the morning for pain, give 30 minutes prior to wound care from 8/16/2025 to 8/20/2025. The MAR indicated on 8/21/2025 Resident 34 refused to take Tylenol oral tablet. RN 2 stated Tylenol Oral tablet 325 mg should not have been administered since 8/16/2025 because the wound was resolved on 8/15/2025. RN 2 stated Resident 34 was receiving unnecessary medication because there was no existing wound or treatment to be done. During a review of the facility's policy and procedure (P&P) titled, Administering Medication, revised 12/2012, the P&P indicated medications shall be administered in a safe and timely manner, and as prescribed. The P&P indicated medications must be administered in accordance with the orders, including any required time frame.
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 to ensure one of four sampled residents (Resident 118), ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 118), received and was provided food that accommodated Resident 118's food preferences.This deficient practice had the potential for Resident 118 to develop further weight loss. Findings:During a review of Resident 118's admission Record (AR), the AR indicated Resident 118 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM II - adult onset disorder characterized by difficulty in blood sugar control), anemia (a condition where the body does not have enough healthy red blood cells) and muscle wasting and atrophy (partial or complete wasting away of a part of the body).During a review of Resident 118's Order Summary Report (OSR) dated 3/31/2025, the OSR indicated CCHO (consistent controlled carbohydrate) regular texture, regular/thin consistency IDDSI (International Dysphagia Diet Standardization Initiative - an international collaboration of professionals who developed a standardized framework for labeling texture-modified foods and thickened liquids) Level 7 (foods are soft, tender, and easy to chew) diet for Resident 118.During a review of Resident 118's Minimum Data Set (MDS - a resident assessment tool) dated 7/7/2025, the MDS indicated, Resident 118 had intact cognition (ability to understand). The MDS indicated Resident 118 was independent (resident completes the activity by themselves with no assistance from a helper) for eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). The MDS indicated Resident 118 had no signs and symptoms of possible swallowing disorder and was on a therapeutic diet (specifically designed meal plan used to treat or manage a specific health condition).During an interview on 8/20/2025 at 9:40 AM with Resident 118, Resident 118 stated, the food at the facility was terrible. Resident 118 stated, Resident 118 had lost eighty pounds since 3/31/2025 because Resident 118 did not eat the food at the facility. Resident 118 stated, Resident 118 needed to lose weight. Resident 118 stated, Resident 118's preference was no bread and no rice, but Resident 118 was served with bread and rice every meal.During a concurrent observation, interview, and record review on 8/21/2025 at 1:00 PM with Resident 118 and the Dietary Supervisor (DS), at Resident 118's bedside, Resident 118's tray card (a card used to identify a person's dietary needs and other important information for meal service, such as a patient's diet, allergies, and dislikes placed on a resident's meal tray) was reviewed. The tray card indicated no bread and liked green salad with tomatoes. Resident 118's meal tray had a bread roll and a small bowl of cut up lettuce only. Resident 118 stated, Resident 118 did not like bread and requested for no bread and the small bowl of cut up lettuce, was not a salad. During a review of the facility's Policy and Procedure (P&P) titled, Resident Food Preferences, revised 7/2017, the P&P indicated the food service department would offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. During a review of the facility's P&P titled, Food and Nutrition Services, revised 10/2017, the P&P indicated, each resident was provided with nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The P&P indicated, reasonable efforts would be made to accommodate resident choices and preferences. The P&P indicated, Food and Nutrition staff would inspect food trays to ensure that the correct meal was provided to each resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the privacy and dignity of seven of seven sam...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the privacy and dignity of seven of seven sampled residents (Resident 11, Resident 27, Resident 33, Resident 45, Resident 116, Resident 136, and Resident 239), by failing to: A. Ensure the privacy curtain was closed while providing care and treatment to Resident 33.B. Ensure Resident 116 did not experience an extended waiting time for care for approximately one hour.C. Ensure Resident 45 and Resident 239 did not experience an extended wait time to receive care for approximately 30 minutes to 2.5 hours.D. Ensure Resident 136 did not experience an extended wait time for peri-care of more than four hours after requesting assistance.E. Ensure Resident 27's personal choices for showers instead of bed bath were respected.F. Ensure Resident 11 did not wait 20 minutes to be changed after soiling her diaper.Findings:
a. During a review of Resident 33's admission Record (AR), the AR indicated Resident 33 was admitted to the facility on [DATE] with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support), and pneumonia (an infection/inflammation in the lungs) due to other specified bacteria.
During a review of Resident 33's MDS dated [DATE], the Minimum Data Set (MDS - a federally mandated resident assessment tool) indicated Resident 33 had severely impaired cognition for daily decision making. The MDS indicated Resident 33 was dependent (helper did all the effort and lifted or held trunk or limbs) on staff for oral hygiene, toileting, showering/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene.
During a concurrent observation and interview on 8/19/2025 at 9:03am with Licensed Vocational Nurse 11 (LVN 11), while in Resident 33's room. Resident 33 was awake, lying in bed. LVN 11 pulled up Resident 33’s gown and checked Resident 33’s GT site. LVN 11 did not close and pull the privacy curtain to provide Resident 33’s privacy which exposed Resident 33’s abdominal area to the roommate and the hallway. LVN 11 stated the privacy curtain needed to be closed prior to providing care and treatment to the residents to provide privacy from the roommate and passerby.
During a concurrent interview on 8/22/2025 at 9:51 am with the facility’s Director of Nursing(DON), the DON stated body parts should not be exposed during care and treatment. The DON stated the resident’s privacy curtain needed to be closed prior to providing care and treatment to residents in order to provide privacy and dignity to the residents.
b. During a review of Resident 116's admission Record (AR), the AR indicated the facility readmitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (sugar in blood is too high) and chronic kidney disease (kidneys are unable to filter waste).
During a review of Resident 116’s History & Physical (H&P), dated 12/17/24, the H&P indicated Resident 116 can make needs known and did not have the capacity to make medical decisions.
During a review of Resident 116's Minimum Data Set (MDS, a resident assessment tool), dated 6/19/25, the MDS indicated Resident 116 was cognitively (ability to understand and process thoughts) intact and required partial to moderate assistance with toileting and personal hygiene, and was always bowel and bladder incontinent.
c). During a review of Resident 239’s admission Record (AR), the AR indicated the facility readmitted to the facility on [DATE] with diagnoses that included methicillin resistant staphylococcus aureus (germ resistant to some antibiotics), and bacteremia (bloodstream infection).
During a review of Resident 239's Minimum Data Set (MDS, a resident assessment tool), dated 8/18/25, the MDS indicated Resident 239 was cognitively (ability to understand and process thoughts) intact and required partial to moderate assistance with toileting and personal hygiene.
During an interview on 8/19/25, at 10:55 a.m., with Resident 239, Resident 239 stated Resident 239 waited up to 2.5 hours for staff assistance to be changed at night. Resident 239 stated this made her feel awful. Resident 239 stated Resident 239 thinks they need more Certified Nurse Assistants (CNAs).
During an interview, on 8/19/25, at 11 a.m. with Resident 116, Resident 116 stated Resident 116 was given a laxative a couple of days ago. Resident 116 stated Resident 116 wasn't taking any more of the laxative because Resident 116 had to keep sheets and blanket pulled back so that stool would not get on blankets. Resident 116 stated Resident 116 had loose stool that was all in between legs on the bed. Resident 116 stated Resident 116 had to wait one hour or more to be changed. Resident 116 stated this happens on all shifts. Resident 116 stated Resident 116 did not like it. Resident 116 stated Resident 116 thinks they need more CNAs.
During an interview, on 8/19/25, at 12:32 p.m., with Resident 45, Resident 45 stated Resident 45 waits 30 minutes to one hour for staff assistance. Resident 45 stated Resident 45 has to wait for staff to get their breaks and lunches before getting help. Resident 45 stated staff turns off the call light and does not assist Resident 45 and if the CNA does not show up, we have to start all over. Resident 45 stated It is not cool but that's the way it is, so we don't make a big deal. Resident 45 stated they don’t have enough workers so we can’t expect much.
During a review of the facility’s Policy and Procedure (P&P), titled, “Dignity,” revised 2021, the policy indicated each resident shall be cared for in a manner that promotes and enhances his of her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during procedures.
During a record review of the facility’s Policy and Procedure (P&P), titled, “Answering Call Lights,” dated 2001, the policy indicated the purpose of this procedure is to ensure timely responses to the resident’s requests and needs.
d. During a review of Resident 136’s AR, the AR indicated Resident 136 was admitted to the facility on [DATE] with diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD- is a common lung disease causing restricted airflow and breathing problems), type 2 diabetes (elevated sugar in the blood), pneumonia (is an infection that inflames the air sacs in one or both lungs), morbid obesity (a person's body has a lot of extra weight) with alveolar hypoventilation (is a breathing disorder that affects some people who have obesity).
During a record review of Resident 136’s H&P, dated 7/17/2025, the H&P indicated Resident 136 did not have the capacity to understand and make decisions.
During a review of Resident 136’s MDS, dated [DATE], the MDS indicated Resident 136 required dependent care (helper does all of the effort, the resident does none of the effort to complete the activity) from staff for toileting hygiene, shower/bathing self and putting on/taking off footwear.
During a review of Resident 136’s Skin Check (SC) dated 7/17/2025 at 2:49 PM, the SC indicated Resident 136 had a new skin issue in the middle area of the sacrum (a triangular bone at the base of the lower back) that was present on admission which was considered to be a pressure ulcer/injury (damage to the skin caused by continuous pressure) Stage 3 full-thickness skin loss (a bedsore where the skin is destroyed and extending into deeper tissue and fat) and surrounding tissue to be fragile with skin that is at risk for breakdown. Additional care areas indicated incontinence management and mattress with pump.
During a review of Resident 136’s CP dated 7/17/2025, the CP indicated Resident 136 had problems with Activities of Daily Living (ADL- referring to fundamental personal care tasks such as bathing, dressing, eating, transferring, toileting, and managing continence) decline in functional mobility skills and a potential for skin break down. The listed goal included to prevent skin breakdown, but there was no ADL maintenance or repositioning included or documented in any other CP in Resident 136’s medical record (MR).
During a review of Resident 136’s Wound Evaluation & Treatment Progress Note (WETPN) dated 8/14/2025, the WETPN indicated Resident 136’s skin exam revealed Resident 136 had a sacrococcyx (the tail bone located at the base of the spine), sacral region (lower back) wound that had closed. The Recommendations indicated to provide aggressive offloading (refers to the practice of relieving or redistributing pressure from a specific area of a patient's body to prevent and treat wounds, especially pressure ulcers) every two (2) hour turning and no sitting beyond two hours; frequent diaper checks and changes. Additional recommendations indicated to turn the patient every two hours and to keep skin clean and dry.
e. During a review of Resident 27’s AR, the AR indicated Resident 27 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (a severe and irreversible condition where the kidneys have lost most of their function and can no longer adequately filter waste products from the blood), cutaneous abscess (a collection of pus under the skin) of the groin (the area between the abdomen and the thigh), laceration with foreign body of right buttock, necrotizing fasciitis (a bacterial infection that enters the body, most commonly through a break in the skin such as a cut, scrape, or burn), morbid (severe) obesity due to excess calories, type 2 diabetes (sugar in the blood) and inflammation of vagina and vulva.
During a review of Resident 27’s MDS dated [DATE], the MDS indicated Resident 27 required substantial/maximal assistance (helper does more than half the effort) from staff for toileting hygiene and upper body dressing. Resident 27 was dependent on staff assistance for shower/bathing self and putting on/taking off footwear and lower body dressing.
During a review of Resident 27’s untitled CP dated 7/24/2025, the CP indicated Resident 27 needs 1-1 activities for social/mental stimulation. The listed Interventions indicated to assess resident for activity preference, respect residents choices and respect resident rights.
During a record review of Resident 27’s H&P, dated 8/17/2025, the H&P indicated Resident 27 does has the capacity to understand and make decisions.
During an initial observation and interview with Resident 27 on 8/19/2025 at 10:04 AM, Resident 27 was observed sitting at the side of bed. Resident 27 stated, “I haven’t taken a shower since three weeks ago. I have only gotten a bed bath one time in three weeks. I do want to take a shower. I’ve been asking for the past three weeks. I brought all my stuff and my shampoo. I want to get clean. When they do peri-care, I don’t feel clean, the staff do it for me. I feel my hair is dirty. I’m all dirty. It makes me feel mad and sad at the same time. I’m a very clean person; it makes me feel staff is not listening to me.”
During initial observation and interview with Resident 136 on 8/19/2025 at 11:03 AM, Resident was observed to be sitting up in bed watching television (TV). Resident 136 stated, “I’ve had a bowel movement (BM) since 7:30 AM. I've been calling them and its 11:07 AM now and I'm still waiting. I’m afraid my wounds will come back. I am very upset and embarrassed. Sometimes I wait up to three (3) hours to get cleaned up. I call and they don’t come.”
During an interview with License Vocational Nurse (LVN9) on 8/19/2025 at 11:11 AM, LVN9 stated Resident 136 should not have been waiting since 7:30 AM to be cleaned up by staff especially if Resident 136 had a bowel movement. LVN9 stated it was not sanitary, and it must be uncomfortable for Resident 136 to be soiled for such a long period of time. LVN9 stated she would go look for Certified Nursing Assistant (CNA4) to have Resident 136 cleaned up. LVN9 stated that CNA4 was assigned to Resident 136 but CNA4 was busy with another resident and that CNA4 would clean up Resident 136 when there was a chance.
During an interview with CNA4 on 8/19/2025 at 11:14 AM, CNA4 stated there were 10 residents on his assignment for the day and someone might have answered the call light earlier and not communicated to CNA4 that Resident 136 was soiled. CNA4 stated he was busy earlier because there was a room change. CNA4 stated that the cnas can feel overworked and burned out at times and feel like they don’t have time to change all the residents in their assignments in a timely manner. I am trying to get to everyone.
During a concurrent interview with CNA4 on 8/20/2025 at 11:39 AM, CNA4 stated, “I do find some of the alert residents that have been waiting for a long period of time tell me the previous shift staff answered the call light but never provided the care they were requesting. Sometimes when I check a resident to clean them up, they are very soiled. They have gone urine or poo once or twice in the same diaper.” Per CNA4, the LVNs or Charge Nurses (CN) are supposed to help, and they can also do the job.
During the same interview with CNA4 on 8/20/2025 at 11:42 AM, CNA4 stated that the residents get showers every other day. Per CNA4 the resident should get the showers for hygiene. CNA4 stated not giving a resident a shower when the resident requests it is not respecting the residents rights and neglecting them. Per CNA4 it would make the resident feel bad, abandoned, neglected, self-conscious and affect their self-esteem.
During a concurrent interview with Resident 27 on 8/20/2025 at 11:54 AM, Resident 27 stated she still had not gotten a shower. Resident 27 stated that the day before, after dinner she had a BM and felt dirty and was itchy on her vaginal area. Resident 27 stated asked the night shift cna to clean her. Per Resident 27, the CNA4 did clean her but did not provide a shower. Resident 27 stated that when the night shift cna cleaned her, the cna showed Resident 27 the towel she used to clean her, and Resident 27 still had poop in her vagina. Per Resident 27 the day shift cna (CNA4) had not cleaned her properly.
During an interview with LVN10 on 8/20/2025 at 11:56 AM, LVN10 stated “Residents have shower schedules either for mornings or evenings, but they all get three (3) showers a week. “They should get showers and peri-care often for hygiene and to prevent infections, skin problems. It is not acceptable to have a resident sitting in their own filth for long periods of time. This can make them feel terrible, helpless, neglected, sad and depressed. Feeling this way puts them at risk for depression or anxiety withdrawal.”
During a concurrent interview with CNA4 while inside Resident 27’s room in the presence of Resident 27 on 8/21/2025 at 8:51 AM, CNA4 stated that Resident 27 should have gotten a shower on Monday 8/18/2025 but that CNA4 still had not been able to give Resident 27 a shower. CNA4 stated Resident 27 would be getting a shower later on that day.
During interview and observation of Resident 27 on 8/21/2025 8:52 AM, Resident 27 begin to cry. Resident 27 stated she was crying because she was so happy that she will finally get a shower today. Resident 27 stated, I have been so embarrassed. The last time my daughter visited me she told me I stink.
During an interview with the Infection Prevention Nurse (IPN) on 8/21/2025 at 3:10pm, IPN stated every resident is scheduled to take a shower at least two times a week. Every resident needs to be provided with peri-care as needed. It’s not acceptable to leave a resident for long periods of time if they are soiled. If there are no restrictions from the wound doctor it’s not acceptable to not give a resident a shower because it’s not good hygiene. IPN also stated that not giving the residents a shower as they requested would make the resident feel uncomfortable, embarrassed and neglected, and their self-esteem would go down making them feel depressed. The IPN stated a resident that is left in soiled conditions for extended periods of time can have serious infection risks, like skin tears, skin inflammation and bedsores. The combination of moisture and bacteria from urine and feces creates an environment that can quickly lead to skin breakdown, and other health complications.
During an interview with the DON on 8/22/2025 at 9:10 AM, the DON stated that it is not acceptable for a resident to be in bed soiled for hours. The DON stated that as soon as a staff identify the resident needs to be changed, the resident needs to be cleaned immediately. The DON stated, “Anyone can do it, including an LVN or RN. This is part of the supervision and mentoring the license nurses must provide to the cna.” The DON further stated if the resident does not receive proper ADLs including peri-care, the resident will be uncomfortable causing them discomfort and irritating their skin.
During an interview with the Treatment Nurse (TN1) on 8/22/2025 at 1:33 PM, TN1 stated that ADLs and timely peri-care must be provided to all residents. TN1 stated especially when residents are at risk of skin breakdown or have wounds it’s extremely important to prevent infections. TN1 stated the main thing is to prevent infections and provide comfort. It’s not acceptable for a resident to be soiled and just have the resident sit there from 7 AM to 11:30 AM. The residents with wounds need to be repositioned as well. Even if the staff is busy, under no circumstances should the resident go for a long period of time without being changed. Per TN1, if a resident is left for long periods of time soiled or not being cleaned completely, it would make the resident feel uncomfortable, embarrassed and neglected.
f. During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood).
During a review of Resident 11's “Minimum Data Set (MDS, a resident assessment tool),” dated 8/5/2025, the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 11 was dependent (helper does all the effort) on staff for bathing, dressing, and toileting hygiene.
During a review of Resident 11’s History and Physical (H&P), dated 6/7/2025, the “H&P” indicated, Resident 11 had the mental capacity to understand and make medical decisions.
During an interview on 8/19/2025 at 1:29 PM with Resident 11, Resident 11 stated Resident 11 had to sometimes wait a long time for help from nurses (in general). Resident 11 stated Resident 11 pressed the call light earlier in the morning of 8/19/2025 because Resident 11 needed Resident 11’s diaper changed. Resident 11 stated Resident 11 waited so long that Resident 11 fell asleep.
During an interview on 8/22/2025 at 8:34 AM with CNA 5, CNA 5 stated facility staff (in general) should respond to residents’ (in general) call lights immediately. CNA 5 stated if residents (in general) were not responded to promptly, residents (in general) would feel like facility staff (in general) were not paying attention to the residents (in general) and that other things were more important than the residents (in general). CNA 5 stated a resident (unidentified) was frustrated with CNA 5 on 8/19/2025 because the unidentified resident waited 10 minutes for CNA 5 to change the unidentified resident’s soiled diaper.
During an interview on 8/22/2025 at 8:47 AM with CNA 6, CNA 6 stated CNA 6 often was assigned to care for Resident 11. CNA 6 stated it sometimes took CNA 6 20 minutes to respond to Resident 11’s request to change Resident 11’s soiled diaper.
During a review of the facility's policy and procedure (P&P) titled, Dignity, revised February 2021, the P&P indicated, “Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example…promptly responding to a resident's request for toileting assistance…” The P&P indicated, “Staff are expected to knock and request permission before entering residents' rooms.”
During a review of the facility's P&P titled, Answering the Call Light, revised September 2022, the P&P indicated, “Answer the resident call system immediately.”
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate the residents' needs and preferences in 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 accommodate the residents' needs and preferences in accordance with the facility's policy and procedures (P&P) for five of five sampled residents (Residents 8, 41, 163,165, and 218) by failing to:a. Provide Resident 8 with an appropriate call light consistent with Resident 8's functional capability.b. Ensure Resident 41's call light was within reach.c. Ensure Resident 163's call light was within reach.d. Ensure Resident 165's bed was not too short causing Resident 165's feet to rest against the footboard. e. Ensure to accommodate Resident 218's request for room change due to noise from the roommate (Resident 209). These failures had the potential for Residents 8, 41, 163, 165, and 218 not to receive necessary care or receive delayed services and could affect the residents' quality of life.Findings:
a. During the review of Resident 8’s admission Record (AR), the AR indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and osteoporosis (weak and brittle bones, due to lack of calcium and vitamin D).
During a review of Resident 8’s untitled Care Plan (CP) dated 10/25/2024, the CP indicated Resident 8 was at risk for falls related to poor safety awareness. The CP interventions included for staff to ensure the call light was within reach and to encourage Resident 8 to use it for assistance.
During a review of Resident 8’s Minimum Data Set (MDS, a resident assessment tool) dated 7/26/2025, the MDS indicated Resident 8 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 8 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with eating, oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene.
During a concurrent observation inside Resident 8’s room and interview on 8/19/2025 at 9:35 am with Certified Nurse Assistant 2 (CNA 2), Resident 8 was lying in bed, on Resident 8’s back. Resident 8 had a push button (a call light that resident presses to signal a nurse or other staff member when they need assistance) type of call light. CNA 2 stated Resident 8 had bilateral (affecting both sides) arms and hands contracture (a stiffening/shortening at any joint, that reduces the joint’s range of motion). CNA 2 stated Resident 8 could not push the call light button and would benefit to use the pad sensor (a communication device used by residents in healthcare facilities to signal for assistance from nursing staff) to call for assistance.
During an interview on 8/21/2025 at 10:01 am with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated residents with limited mobility would benefit to have the pad sensor for the resident to use to call for assistance and staff could address the resident’s needs timely.
During an interview on 8/21/2025 at 11:50 am with the Director of Nursing (DON), the DON stated call light should be appropriate to the resident’s functional capability for the residents to use and call for assistance whenever help was needed.
During a review of the facility’s policy and procedures (P&P) titled, “Call System, Residents,” dated September 2022, the P&P indicated, “Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.”
b. During a review of Resident 41’s AR, the AR indicated Resident 41 was admitted to the facility on [DATE] with diagnoses that included acute embolism (a medical emergency caused by a sudden blockage in a blood vessel by a traveling clot) and thrombosis (a blood clot) of unspecified deep veins of the right lower extremity (right leg), type 2 diabetes mellitus (elevated sugar in the blood), chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood) and major depressive disorder (persistent feeling of sadness and loss of interest).
During a review of Resident 41’s History and Physical (H&P) dated 7/29/2025, the H&P indicated Resident 41 can raise needs known but cannot make medical decisions.
During a review of Resident 41’s MDS dated [DATE], the MDS indicated Resident 41 was dependent on staff for personal and toileting hygiene, shower/bathing self, upper and lower body dressing and putting on/taking off footwear.
During a review of Resident 41’s untitled CP dated 8/4/2025, the CP indicated Resident 41 was high risk for falls related to deconditioning and psychoactive drugs use. The CP interventions indicated for staff to ensure the resident’s call light was within reach and to encourage the resident to use it if assistance was needed.
During an observation in Resident 41’s room and interview with Resident 41 on 8/19/2025 at 9:58 AM, Resident 41 was resting in bed and the call light was hanging down from the side of the bed. Resident 41 stated Resident 41 could not reach the call light to call for assistance.
During an interview with CNA 4 on 8/20/2025 at 11:39 AM, CNA 4 stated the call light was supposed to be next to the resident’s hands and within reach so that the resident could get hold of the staff if assistance was needed.
During an interview with Registered Nurse Supervisor (RN5) on 8/21/2025 at 9:18 AM, RN5 stated the resident’s call light needed to be within reach, near the resident’s hands, to give access for the resident to call for assistance from staff. RN5 stated, if the resident does not have the call light access the resident could not call for help and the resident could have an accident.
During an interview with the facility’s Director of Nursing (DON) on 8/22/2025 at 8:58 AM, the DON stated it was important for the residents to know they can access the call light at any time specially if they feel the need to call for assistance. The DON stated, not having the call light within reach placed the resident at a greater risk for falls, injury, and delayed medical care, which can lead to serious complications.
During a review of the facility’s P&P titled, “Answering the Call Light”, revised September 2022, the P&P indicated to ensure timely responses to the resident’s requests and needs.
During a review of the facility’s P&P titled, “Call System”, revised September 2022, the P&P indicated, “Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member of centralized workstation.”
During a review of the facility’s P&P titled, “Accommodation of Needs”, revised March 2021, the P&P indicated the facility’s environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being.”
During a review of the facility’s P&P titled, “Dignity”, revised February 2021, the P&P indicated, “Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.”
c. During a review of Resident 163's AR, the AR indicated Resident 163 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (decrease in size or wasting away of a body part or tissue).
During a review of Resident 163's untitled CP dated 8/27/2024, the CP indicated Resident 163 was at risk for falls related to resident’s unawareness of safety needs. The CP intervention indicated for nursing staff to ensure Resident 163’s call light was within reach and encourage the resident to use it for assistance as needed. The CP intervention also indicated Resident 163 needed a prompt response to all requests for assistance.
During a review of Resident 163's Fall Risk Evaluation (FRE) dated 10/22/2024, the FRE indicated Resident 163 had intermittent confusion and required the use of assistive devices.
During a review of Resident 163's MDS dated [DATE], the MDS indicated Resident 163 had moderately impaired cognition for daily decision making. The MDS indicated Resident 163 needed moderate assistance for eating and oral hygiene. The MDS indicated Resident 163 was dependent on staff for showering/bathing self, lower body dressing and putting on/taking off footwear.
During an observation on 8/19/2025 at 9:19 am, Resident 163 was awake, lying in bed. Resident 163 stated “I don’t know where my call button is. I couldn’t reach it.”
During a concurrent observation and interview on 8/19/2025 at 9:21 am, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 163’s call light was clipped on Resident 163’s upper left side of the bed. LVN 1 stated, the call light needed to be within reach of the resident all the time. LVN 1 stated Resident 163’s needs would not be met if the call light was not within reach.
During a concurrent observation and interview on 8/22/2025 at 10:16 am with Director of Nursing (DON), the DON stated the resident’s call light needed to be accessible by the resident at all times. The DON stated, if the call light was not within reach, the resident would not be able to request help or assistance from staff and staff would not be able to accommodate the resident’s needs.
During a review of the facility's P&P titled, Call System, Residents, dated 9/2022, the P&P indicated each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.
d. During a review of Resident 165's AR, the AR indicated Resident 165 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure (when the lungs can't get enough oxygen into the blood), traumatic brain injury, and persistent vegetative state (a state of brain injury where the resident is awake but has no consciousness of self or their environment). The AR indicated Resident 165’s mother (RP 1) was Resident 165’s Responsible Party.
During a review of Resident 165’s H&P dated 6/24/2025, the H&P indicated Resident 165 did not have the mental capacity to understand and make medical decisions.
During a review of Resident 165's MDS dated [DATE], the MDS indicated Resident 165 was dependent on staff for all activities of daily living (ADL, a term used to describe the skills required to independently care for oneself). The MDS indicated Resident 165 was 72 inches tall.
During a concurrent observation and interview on 8/19/2025 at 9:48 AM with RP 1 in Resident 165’s room, Resident 165’s feet were hanging past the foot of Resident 165’s bed. RP 1 stated if RP 1 had not raised the mattress at the foot of Resident 165’s bed then Resident 165’s feet would rest against the foot board. RP 1 stated RP 1 had requested a longer bed in the past, but facility staff (unidentified) had claimed there were no other beds available for Resident 165.
During a concurrent observation and interview on 8/21/2025 at 11:51 AM with Licensed Vocational Nurse 12 (LVN 12) in Resident 165’s room, RP 1 and LVN 12 placed Resident 165’s mattress flat at the foot of the bed. Resident 165’s feet rested on the foot board when the mattress was flat. LVN 12 confirmed Resident 165’s bed was too short for Resident 165.
During an interview on 8/21/2025 at 12:50 AM with Registered Nurse 1 (RN1), RN 1 stated if residents’ (in general) feet were touching the footboards of the beds then residents (in general) could acquire a pressure sore at that location.
During a review of the facility's P&P titled, “Accommodation of Needs,” revised March 2021, the P&P indicated, “The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered…The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.”
e. During a review of Resident 218’s AR, the AR indicated Resident 218 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) and functional quadriplegia (complete or partial paralysis of arms and legs).
During a review of Resident 218’s MDS dated [DATE], the MDS indicated Resident 218 had severely impaired decision making and was dependent on family members to assist in communication of care needs.
During a review of Resident 218’s untitled CP dated 10/20/2024, the CP indicated Resident 218 needed social and mental stimulation activities. The CP intervention included to respect the resident’s choices. In addition, Resident 218’s Care Plans did not include social services to address Resident 218’s request for room changes or support to Resident 218 for emotional distress.
During a review of Resident 209’s AR, the AR indicated Resident 209 was admitted on [DATE] with diagnoses including Metabolic Encephalopathy (a brain dysfunction due to chemical imbalance in the body), Oropharyngeal phase dysphagia (a problem with swallowing process that moves food from the mouth to the throat).
During a review of Resident 209’s MDS dated [DATE], the MDS indicated Resident 209 had severely impaired cognitive skills for daily decision making.
During a review of Resident 209’s untitled CP dated 7/10/2025, the CP indicated Resident 209 had impaired communication related to Aphasia (difficulty understanding and speaking).
During an observation on 8/19/2025 at 11:55 a.m., Resident 209 was lying supine (positioned on back) in bed with a call light within reach. Resident 209 was screaming loudly but did not press the call light.
During an interview on 8/19/2025 at 8:59 a.m. with Resident 218’s Family Member 1 (FM1), FM 1 stated Resident 218’s has had four roommates that have died in the same room where Resident 218 was and Resident 218 was sad and would cry because of the deaths. FM 1 stated Resident 218 could not sleep well because of the nose from Resident 209. FM 1 stated a room change was requested by FM 1 “four months ago” for Resident 218 and requested a roommate that could communicate with Resident 218. FM1 stated it would be better if the roommates could communicate with Resident 218.
During an interview and record review of Residents 218 and 209’s medical records on 8/21/2025 at 2:08 p.m. with the Social Services Director 1 (SSD 1), SSD 1 stated roommates were assigned based on their age and health condition, such as the same type of infection. SSD 1 stated it was the facility’s responsibility to review roommate selections and determine recommendations. SSD 1 stated there was no warning when Resident 209 made noise and SSD 1 did not find a pattern why Resident 209 made the noise. SSD 1 stated due to isolation, Resident 218 and 209 needed to stay in one room. A review of both residents’ admission records did not indicate a common infection. The current (active) Social Services care plan for Resident 218 dated November 2024 did not include a care plan to address Resident 218’s concerns about the noise from the roommate (Resident 209) nor any documentation of social services visiting Resident 218 regarding a room change.
During a review of the facility’s P&P titled “Care Plans, Comprehensive Person-Centered” dated March 2022, the P&P indicated the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure its policies and procedures (P&P) for Advance Directive (AD,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure its policies and procedures (P&P) for Advance Directive (AD, a written preference regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) was implemented for three of three sampled residents (Resident 7, 16 and 119) by failing to: a. Ensure Resident 7's AD was discussed and written information was provided to the residents and/or responsible parties.b. Ensure Resident 16's AD was discussed and written information was provided to the residents and/or responsible parties.c. Ensure Resident 119's Advance Directive Acknowledgement (ADA) Form was completed upon admission.These failures had the potential to result in facility staff to provide medical treatment and services against the residents' will.
Findings:
a. During a review of Resident 7’s admission Record (AR), the AR indicated Resident 7 was admitted on [DATE] with diagnoses that included anxiety (emotion characterized by an unpleasant state of inner turmoil), depression (a feeling of severe sadness or hopelessness) and bipolar disorder (mental disorder with periods of depression and periods of elevated mood).
During a review of Resident 7’s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 7/5/2025, the MDS indicated Resident 7 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 7 needed maximum assistance (helper did more than half the effort and lifted or held trunk or limbs) to staff for lower body dressing. The MDS indicated Resident 7 needed moderate assistance (helper did less than half the effort) from staff for toileting hygiene, shower, upper body dressing and putting on/taking off footwear.
During an interview and concurrent record review on 8/19/2025 at 10:41 am, with Licensed Vocational Nurse 4 (LVN 4) of Resident 7’s medical records (chart), LVN 4 stated their was no ADA Form in the physical chart or the PointClickCare (PCC, a cloud-based software used in long-term and post-acute care facilities and chart). LVN 4 stated ADAF should be accessible in the resident's chart in order to know the residents' medical wants in cases of emergency.
b. During a review of Resident 16's AR, the AR indicated Resident 16 was admitted to the facility on [DATE] with diagnoses that included Chronic kidney disease (CKD) is a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood and diabetes mellitus type 2 (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine).
During a review of Resident 16’s MDS dated [DATE], the MDS indicated, Resident 16’s had moderately impaired cognition for daily decision making. The MDS indicated Resident 16 needed moderate to staff for eating and oral hygiene.
During an interview and concurrent record review on 8/19/2025 at 10:16 am, with the LVN 4 of Resident 16’s medical records (chart) the LVN 4 stated their was no ADAF in the physical chart and PCC. The LVN 4 stated ADAF should be accessible in the chart to know the residents medical wants and in cases of emergency.
During an interview and concurrent record review on 8/19/2025 at 10:19 am, with the Social Service Designee (SSD), the SSD stated he was unable to find Resident 16’s ADA Form in the chart. The SSD stated, ADA Form needed to be in Resident 16’s clinical records upon admission to know Resident 16’s wishes and to access the form immediately in case of emergency.
During an interview on 8/22/2025 at 9:56 am, with the facility's Director of Nursing (DON), the DON stated, ADAF needed to be initiated and filled out completely upon admission by Social Services to assess if resident executed an AD or wanted to execute to know the residents preference of care and to proceed what treatment to be given to the resident in case of emergency.
During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, dated 9/2022, the P&P indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The P&P indicated advance directives are honored in accordance with state law and facility policy. The P&P indicated prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The P&P indicated the resident, or representative is provided with written information… to formulate an advance directive if he or she chooses to do so. The P&P indicated information about whether or not the resident has executed an advance directive is displayed prominently in the medical record that is retrievable by any staff.
c. During a review of Resident 119’s admission Record (AR), the admission Record indicated Resident 119 was admitted on [DATE] with diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).
During a review of Resident 119’s History & Physical (H&P), dated 2/19/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 119’s Minimum Data Set assessment (MDS – a federally mandated resident assessment tool), dated 7/26/2025, the MDS indicated Resident 119 had moderately impaired cognition (ability to think).
During a review of Resident 119’s undated Advance Directive Acknowledgment Form, the ADA Form indicated there was no acknowledgement from the resident or responsible party (RP) of being given written material and being informed about rights to accept or refuse medical treatments. There was no information of rights to formulate an AD, no obligation to formulate an AD and if any AD was executed and it would be followed by the facility and it’s caregivers, and if the resident or RP declined or wished to execute an AD.
During a concurrent interview and record review on 8/20/2025 at 9:38 am with Social Services Director 1 (SSD 1), Resident 119’s undated, Advance Directive Acknowledgment Form (AD - a legal document indicating resident preference on end-of-life treatment decisions) form was reviewed. The AD Acknowledgement Form was blank except the resident’s name, physician, date of admission, and medical record name. SSD 1 stated, it was his job to talk about the resident’s rights to formulate an Advance Directive with the responsible party. SSD 1 stated he was responsible for completing the AD Acknowledgement Form, which should have been completed upon the resident’s admission.
During an interview on 8/22/2025 at 9:56 am with the Director of Nursing (DON), the DON stated the AD Acknowledgement Form should be done upon the resident’s admission to allow the staff to know the resident’s preference of care and treatments in case of an emergency.
During a review of the facility’s policy and procedure (P&P) titled, “Advance Directives,” last revised 9/2022, the P&P indicated, prior to or upon admission of a resident, the SSD or designee inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written AD. The P&P indicated the resident or representative be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an AD if he or she chooses to. The P&P indicated, written information included a description of the facility’s policies to implement AD and applicable law. The P&P indicated if the resident was incapacitated and unable to receive information about his/her right to formulate an AD, the information may be provided to the resident’s legal representative.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of two sampled residents' (Resident 9's and Resident 13'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of two sampled residents' (Resident 9's and Resident 13's), Minimum Data Set (MDS - a resident assessment tool) assessments were accurately documented to reflect:a. Resident 9's use of oxygen.b. Resident 13 was receiving hospice care.These failures had the potential to negatively affect Resident 9‘s and Resident 13's plan of care and delivery of necessary care and services.Findings:
a. During a review of Resident 9’s admission Record (AR), the admission Record indicated Resident 9 was admitted on [DATE] with diagnoses that included respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide from the lungs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and heart failure (when the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen).
During a review of Resident 9’s History & Physical (H&P), dated 5/12/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 9’s Minimum Data Set assessment MDS, dated [DATE], the MDS indicated Resident 9 had moderately impaired cognition (ability to think) and did not indicate oxygen therapy was used in the last 14 days while the resident was in the facility.
During a review of Resident 9’s Care Plan (CP), dated 1/18/2025, the CP indicated, Resident 9 had oxygen therapy related to heart failure and respiratory illness.
During a review of Resident 9’s Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 7/1/2025 to 7/31/2025, the MAR indicated Resident 9 received oxygen every day from 7/1/2025 to 7/31/2025.
During an interview on 8/19/2025 at 9:04 am with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 9 was on two liters of oxygen via nasal cannula.
During a concurrent interview and record review on 8/22/2025 at 9:59 am with Minimum Data Set Coordinator (MDS C), MDS C reviewed Resident 9's MDS, dated [DATE]. MDS C stated Resident 9 was on oxygen at the time of the assessment and was on oxygen during the whole month of July 2025. MDS C stated the MDS assessment was done to accurately collect the data of what a patient received for their plan of care. MDS C stated not indicating in the MDS, dated [DATE], that Resident 9 used oxygen was a data entry error.
During an interview on 8/22/2025 at 12:12 pm with the Director of Nursing (DON), DON stated MDS was a comprehensive assessment of patient care and what they were doing for their care. DON stated, the data was transmitted to CMS and needed to be accurate, and if it wasn’t, it would need a correction.
During a review of the facility’s policy and procedure (P&P) titled, “Resident Assessments,” last revised March 2022, the P&P indicated “all persons who completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.”
b. During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was readmitted to the facility on [DATE] with diagnoses that included encephalopathy (brain disease), respiratory failure, and Parkinsonism (brain conditions that cause slowed movements, stiffness and tremors).
During a review of Resident 13’s H&P, dated 6/10/2025, the H&P indicated Resident 13 did not have the capacity to make medical decisions.
During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13 was severely cognitively impaired and was dependent on others with toileting and personal hygiene. The MDS did not indicate Resident 13 was receiving hospice services.
During a review of the Physician’s Certification for Hospice Services (PCHS), dated 6/20/2025, the PCHS indicated Resident 13’s hospice services certification period was 6/20/2025 to 9/17/2025.
During a review of Resident 13’s MDS, dated [DATE], the MDS did not indicate Resident 13 was receiving hospice services.
During a concurrent interview and record review, on 8/22/2025, at 4:10 p.m., with Minimum Data Set Assistant (MDS A), MDS A stated the MDS, dated [DATE], was miscoded. MDS A stated Resident 13’s MDS should have been coded as hospice because Resident 13 was on hospice services. MDS A stated Resident 13 was placed on hospice on 6/20/2025.
During a review of the facility’s P&P, titled, “MDS Error Correction,” revised September 2010, the P&P indicated, If an error is discovered after encoding period and the record in error is an OBRA assessment, determine if the error is major or minor. A minor error is one related to the coding of the MDS. For minor errors, correct the record and submit to QIES ASAP system. A major error is one that accurately reflects the resident’s clinical status and/or may result in an inappropriate plan of care .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop an individualized and person-centered care plan for two of f...
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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 an individualized and person-centered care plan for two of five sampled residents (Resident 13 and Resident 33) in accordance with the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, by failing to ensure:a. Resident 13, who had a diagnosis of dementia (a progressive stated of decline in mental abilities), had a plan of care for dementia.b. Resident 33's peripherally inserted central catheter (PICC - a long, thin catheter inserted into a vein in the arm, usually in the upper arm, and threaded to a large vein near the heart, used to administer fluids and or medications) was included in Resident 33's plan of care.These deficient practices had the potential for Resident 13 and Resident 33 to not receive appropriate care, treatment, and or services.Findings:
a. During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was readmitted to the facility on [DATE] with diagnoses that included encephalopathy (brain disease), dementia (a progressive state of decline in mental abilities), and Parkinsonism (brain conditions that cause slowed movements, stiffness and tremors).
During a review of Resident 13’s History & Physical (H&P), dated 6/10/2025, the H&P indicated Resident 13 did not have the capacity to make medical decisions.
During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool), dated 8/9/2025, the MDS indicated Resident 13 was severely cognitively (ability to understand and process thoughts) impaired and was dependent on staff with toileting and personal hygiene.
During a concurrent interview and record review, on 8/22/2025, at 11:45 a.m., with Registered Nurse (RN 6), RN 6 stated Resident 13 had a diagnosis of dementia. RN 6 reviewed Resident 13’s electronic medical record (EMR) and stated there was no care plan for dementia found in Resident 13’s EMR. RN 6 reviewed Resident 13’s hospice (end of care) binder and was unable to find a care plan for dementia. RN 6 stated Resident 13 should have a care plan for dementia because Resident 13 had a diagnosis of dementia.
b. During a review of Resident 33's AR, the AR indicated Resident 33 was admitted to the facility on [DATE] with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support), and pneumonia (an infection/inflammation in the lungs).
During a review of Resident 33's MDS dated [DATE], the MDS indicated Resident 33 had severely impaired cognition for daily decision making. The MDS indicated Resident 33 was dependent (helper did all the effort and lifted or held trunk or limbs) on staff for oral hygiene, toileting, showering/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene.
During a concurrent interview and record review on 8/20/2025 at 3:30 pm with Registered Nurse 1 (RN 1) of Resident 33’s electronic medical records, RN 1 stated there was no clinical documentation that a care plan was initiated for the management of Resident 33’s PICC line. RN 1 stated a care plan should have been initiated and implemented for Resident 33’s PICC line use.
During an interview on 8/22/2025 at 10:01 am with the facility’s Director of Nursing (DON), the DON stated, Resident 33’s care plan for PICC line use must be initiated and implemented to provide proper care and interventions to Resident 33’s PICC line.
During a review of the facility's P&P titled, “Comprehensive Person – Centered,” revised 3/2022, the P&P indicated, “A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial, and functional needs is developed and implemented for each resident.”
CONCERN
(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 observation, interview and record review, the facility failed to ensure three of three sampled residents (Residents 8, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of three sampled residents (Residents 8, 11, and 58) received treatment and care in accordance with physician's orders/professional standards of practice when:a. The facility failed to provide a bolstered mattress to Resident 8, as ordered. b. The facility failed to provide treatment for Resident 11's complaint of burning pain when urinating. c. The facility failed to manage the pain & burning sensation upon urination for Resident 58. These failures resulted in Residents 11 and 58 continuing to experience burning pain when urinating and had the potential for Residents 8, 11, and 58 to experience a decline in health and wellbeing.(Cross Reference F580 and F697)
Findings:
a. During the review of Resident 8’s admission Record (AR), the AR indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and osteoporosis (weak and brittle bones, due to lack of calcium and vitamin D).
During a review of Resident 8’s Order Summary Report (OSR), dated 9/10/2024, the OSR indicated Resident 8 had an order to have bolstered mattress when in bed for mobility and positioning.
During a review of Resident 8’s untitled Care Plan (CP) dated 10/25/2024, the CP indicated Resident 8 was at risk for falls related to poor safety awareness. The CP interventions included following the facility fall protocol.
During a review of Resident 8’s Fall Risk Evaluation (FRE) dated 7/24/2025, the FRE indicated Resident 8 was at risk for fall.
During a review of Resident 8’s Minimum Data Set (MDS, a resident assessment tool) dated 7/26/2025, the MDS indicated Resident 8 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 8 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with eating, oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene.
During a concurrent observation inside Resident 8’s room and interview on 8/19/2025 at 9:35 am with Certified Nurse Assistant 2 (CNA 2), Resident 8 was lying in bed, on Resident 8’s back. CNA 2 stated Resident 8 did not have a bolstered mattress in place.
During a concurrent interview and record review on 8/20/2025 at 10:00 am with Licensed Vocational Nurse 1 (LVN 1), Resident 8’s OSR dated 9/10/2024 was reviewed. LVN 1 stated Resident 8 had an order for a bolstered mattress when in bed. LVN 1 stated the doctor’s order should have been carried out as soon as the order was received for the safety of Resident 8.
During an interview on 8/21/2025 at 11:48 am with the Director of Nursing (DON), the DON stated all doctor’s orders should be carried out immediately to avoid delay in care and treatment.
During a review of the facility’s Policy and Procedure (P&P) titled, “Medication and Treatment Orders, Dental Services,” revised February 2014, the P&P indicated, “Medication orders and treatment will be administered by nursing service personnel as soon as possible as the order has been received. All orders must be charted and made part a part of the resident’s medical record and care plan.”
b. During a review of Resident 11's AR, the AR indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood).
During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 11 was dependent (helper does all the effort) on staff for bathing, dressing, and toileting hygiene.
During a review of Resident 11’s History and Physical (H&P) dated 6/7/2025, the H&P indicated Resident 11 had the capacity to understand and make medical decisions.
During a review of Resident 11’s CP titled “Risk for Impaired Urinary Elimination…,” dated 7/29/2025, the CP indicated facility staff needed to notify Resident 11’s healthcare provider immediately if Resident 11 had any voiding (urinating) abnormalities. The care plan indicated to monitor signs and symptoms of UTI.
During an interview on 8/19/2025 at 1:35 PM with Resident 11, Resident 11 stated Resident 11 had been recently treated for a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). Resident 11 stated Resident 11 currently had another UTI because Resident 11 felt a burning pain when Resident 11 urinated. Resident 11 stated Resident 11 had told multiple nurses (unidentified) about Resident 11’s burning pain with urination, but the unidentified nurses told Resident 11 that Resident 11 was “fine.”
During an interview on 8/19/2025 at 2:00 PM with Licensed Vocational Nurse 9 (LVN 9), the surveyor informed LVN 9 that Resident 11 complained of burning pain when Resident 11 urinated. LVN 9 stated LVN 9 would go and evaluate Resident 11.
During an interview on 8/20/2025 at 10:06 AM with Resident 11, Resident 11 stated Resident 11 still felt burning pain when Resident 11 urinated. Resident 11 stated Resident 11 had complained to multiple staff (unidentified) about the pain on 8/19/2025 but no one did anything about Resident 11’s complaint.
During an interview on 8/20/2025 at 10:09 AM with LVN 9, LVN 9 confirmed Resident 11 had complained to LVN 9 that Resident 11 experienced burning pain when Resident 11 urinated. LVN 9 stated LVN 9 did not notify Resident 11’s doctor of Resident 11’s complaint of burning when urinating. LVN 9 stated LVN 9 notified Registered Nurse 4 (RN 4) about Resident 11’s complaint of burning when urinating.
During an interview on 8/20/2025 at 10:15 PM with RN 4, RN 4 stated burning when urinating is a symptom of a UTI. RN 4 stated if a resident (in general) complained of burning when urinating, staff should call the resident’s (in general) physician. RN 4 stated the doctor would usually order laboratory, including a urine analysis (urine sample to screen for UTI as well as other diseases and conditions). RN 4 stated RN 4 did not notify Resident 11’s doctor of Resident 11’s complaint of feeling burning pain when urinating. RN 4 stated Resident 4 would likely need an antibiotic (a medication that kills or inhibits the growth of bacteria) if Resident 11 had a UTI.
During a concurrent interview and record review on 8/21/2025 at 9:06 AM with RN 1, Resident 1’s laboratory report (LR) titled, “Urinalysis”, collected 8/20/2025 was reviewed. The LR indicated Resident 11’s urine showed a large amount of Leukocyte esterase (an enzyme test that detects the presence of white blood cells [WBCs] or their enzymes in the urine, which often signals a UTI) and positive for nitrite (could indicate a bacterial UTI). RN 4 stated Resident 11’s LR indicated Resident 11 had a UTI. RN 4 stated LVN 9 should have notified Resident 11’s doctor about Resident 11’s complaint of feeling burning pain when urinating on 8/19/2025, to get a treatment order to address Resident 11’s discomfort.
During a review of the facility's Policy and Procedure (P&P) titled, “Change in a Resident’s Condition or Status” revised 11/2015, the P&P indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The P&P indicated the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been…A significant change in the resident's physical/emotional/mental condition…A need to alter the resident's medical treatment significantly.
c. During a review of Resident 58's AR, the AR indicated Resident 58 was admitted to the facility on [DATE] with diagnoses that included pericardial effusion (buildup of fluid in the membrane that surrounds the heart), Type 2 diabetes mellitus (elevated blood sugar levels) with chronic kidney disease (kidneys unable to filter waste), and chronic obstructive pulmonary disease (blocked airflow making it difficult to breathe).
During a review of Resident 58’s Physician’s Order (PO) dated 9/7/24, the PO indicated for licensed staff to administer Acetaminophen Oral Tablet 325 milligrams (mg-unit of measurement), 2 tablets by mouth, every four hours as needed for pain management, mild pain (1-3).
During a review of Resident 58’s PO dated 9/7/24, the PO indicated for licensed staff to administer Acetaminophen-Codeine Oral tablet 300-60 mg, one tablet by mouth, every four hours as needed for pain management for moderate to severe pain.
During a review of Resident 58's History & Physical (H&P) dated 9/9/24, the H&P indicated Resident 58 had the capacity to make medical decisions.
During a review of Resident 58’s Physician Orders (PO) dated 11/10/24, the PO indicated pain assessment every shift: 0-No Pain, 1-3 mild pain,4-6 moderate pian, 7-10 severe pain.\
During a review of Resident 58's Minimum Data Set (MDS, a resident assessment tool) dated 6/6/25, the MDS indicated Resident 58 was cognitively intact (ability to understand and process thoughts), and required substantial/maximal assistance with toileting and personal hygiene.
During a review of Resident 58’s short term care plan dated 7/21/25 for pain when urinating, the CP indicated for nursing staff to notify Resident 58’s physician (MD) of any changes.
During an interview on 8/20/25 at 8:34 a.m., Resident 58 stated Resident 58 had pain when urinating for three weeks. Resident 58 stated Resident 58 had taken two antibiotics but Resident 58 had no relief. Resident 58 stated Resident 58 told “everybody” in the facility that Resident 58 still had urinary pain but the facility staff did not address her complaint of pain.
During an interview on 8/20/25 at 3:45 p.m., Resident 58 stated Resident 58 had radiating 10/10 back pain when urinating, based on the pain scale (0= no pain, 10=worst pain).
During a concurrent interview and record review on 8/20/25 at 4:30 p.m. with Licensed Vocational Nurse (LVN 3) of Resident 58’s Progress Notes (PN) dated 8/18/25, the PN indicated Urine Analysis (UA) and Culture and Sensitivity (C&S- used to identify the specific bacteria causing infection). LVN 3 stated the UA and C&S were not carried out. LVN 3 stated licensed staff needed to check the physician (MD)/ Family Nurse Practitioner (FNP) Progress Note following a physician’s assessment.
During an interview on 8/20/25 at 5:20 p.m. at Resident’s 58’s bedside, Resident 58 stated Resident 58 had pain when urinating.
During a phone interview on 8/22/25, at 8:55 a.m. with the FNP, the FNP stated the plan for a UA and CS was communicated to the nursing staff on 8/18/25 after FNP assessed Resident 58 but the FNP stated the FNP did not know the licensed nurse’s name to whom the plan was communicated. The FNP stated the UA & CS for Resident 58 was missed. The FNP stated, the FNP would communicate orders verbally after resident assessments during on site to the nursing staff and a telephone order was written. The FNP stated Pyridium (a urinary analgesic that relieves pain) administration for pain upon urination was delayed. The FNP stated the FNP would refer residents to Urology (medical specialty that focuses on diagnosis and treatment of disorders related to the urinary tract system) but Resident 58 was not referred to Urology.
During an interview on 8/22/25 at 10:34 a.m., with LVN 15, LVN 15 stated Resident 58 had a history of UTI. LVN 15 stated the care plan to address pain upon urination was not revised. LVN 15 stated the care plan was important because the care plan had interventions to manage the problem and track actions being taken to prevent further symptoms on the resident.
During a record review of Resident 58’s electronic medical record (EMR), a Situation, Background, Assessment, and Recommendation (SBAR- helps team share information), was not found indicating Resident 58 complained of pain when urinating, indicating a change in Resident 58's condition.
During a review of Resident 58’s Electronic Medical Record (EMR), the EMR did not indicate a Situation, Background, Assessment, and Recommendation (SBAR- helps team share information) for Resident 58’s complaint of dysuria noted in the MD progress note dated 8/18/25.
During a review of the facility’s Policy and Procedure (P&P), titled, “Pain Assessment and Management,” revised April 2018, the P&P indicated the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident’s choices related to pain management.
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, for five of five sampled residents, the facility failed to ensure:a. Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for five of five sampled residents, the facility failed to ensure:a. Resident 218's blisters under the ostomy bag were assessed.b. Resident 212's LAL mattress (tiny laser made air holes in the mattress top surface continually blowing out air causing the resident to float) was set up accurately according to manufacturer's instruction and not on static mode.c. Resident 213's LAL mattress was not set to static while the resident was in bed.d. The LAL mattress was set according to Residents 41 and 136's weight. These deficient practices placed the residents at risk for altered skin integrity and had the potential to result in the development/worsening of pressure ulcers (PU - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).Findings:
a. A review of Resident 218’s admission Record (AR) dated 10/19/2024, the AR indicated that Resident 218 has hemiplegia (partial paralysis) and hemiparesis (weakness or inability to move on one side of the body) following a cerebral infarction (a condition where blood flow to the brain is interrupted, leading to damage or death of brain cells) affecting the left non-dominant (no control over) side and functional quadriplegia (a condition in which a person is completely immobile due to sever disability or frailty, but without any underlying brain or spinal cord injury).
A review of Resident 218’s Care Plan Report (CP) dated 12/2/2024, the CP indicated that Resident 218’s body was to be checked for skin breaks and treated promptly as ordered by doctor. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length, width, and depth).
A review of Resident 218’s Minimum Data Summary (MDS) dated [DATE], the MDS indicated that Resident 218 was dependent on staff for personal hygiene.
During an observation on 8/19/2025 at 8:59 a.m., two blisters were seen at the left lower side of Resident 218’s abdomen, under an ostomy bag.
A review of Resident 218’s Order Summary Report dated 8/20/2025, the order summary report did not indicate there were blisters at the left lower area of the abdomen, beneath or near the ostomy bag.
During an observation and interview on 8/20/2025 at 2:08 pm with LVN 9, LVN 9 stated they did not know about the blisters under the ostomy bag and would report it to the treatment nurse. LVN 9 continued to explain, whoever sees it is responsible for reporting and taking care of it.
A review of the Prevention of Pressure Injuries policy, dated December 2016, under Skin Assessment, item 3, the facility is to inspect the skin on a daily basis when performing or assisting with personal care or ADLs; and under Monitoring, item 1, Evaluate, report, and document potential changes in the skin.
b. During a review of Resident 212's admission Record (AR), the AR indicated Resident 212 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer (lesion/wound caused by type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine) with other specified complication and non-pressure chronic ulcer of left heel and midfoot with unspecified severity.
During a review of Resident 212's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/2/2025, the MDS indicated Resident 212 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 212 was dependent (helper does all of the effort) on staff for eating, oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/off footwear and personal hygiene.
During a review of Resident 212's Order Summary Report (OSR) dated 8/30/2024, the OSR indicated Resident 212 may have a low air loss mattress for skin management.
During a review of Resident 212’s Monthly Weight Report (MWR), the MWR indicated Resident 212 was 114 pounds (lbs, unit of measurement) on 8/2025.
During an observation on 8/19/2025 at 9:49 am, Resident 212 was awake and lying on bed with LAL mattress. Resident 212’s LAL mattress was set at 320 lbs. The light was switched to “ON” indicating on static setting.
During an observation and concurrent interview on 8/19/2025 at 9:52 am, with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated the LAL mattress was set on 320 lbs. The LVN 4 stated the LAL mattress needed to be set up according to Resident 212’s actual weight. LVN 4 stated the light was on and it indicated the LAL was set on static setting. The LVN 4 stated, LAL mattress needed to be on alternating mode and not on static setting to alternate the airflow in the mattress to prevent Resident 212 from developing a pressure injury.
During an interview on 8/22/2025 at 10:11 am with the facility's Director of Nursing (DON), the DON stated the LAL mattress needed to be set up based on residents actual weight for it would not serve the purpose which to prevent from developing pressure injury if not set up based on the residents’ weight. The DON stated, LAL should not be on static mode and needed to be on alternating mode to avoid firmness and to take off the pressure from the residents back.
During a review of the undated user manual titled, Proactive Medical Products Operation Manual, the user manual indicated the pressure adjust knob (adjustable by patient’s weight) to determine the patients weight and set the control knob to that weight setting on the control unit. The manual indicated static/alternating control, press ON to set the air mattress to static mode or OFF to set alternating pressure mode. The manual indicated to press the static button to shift between alternating mode and static mode. When in static mode, the static indicator will come on. The static mode will be started approximately six minutes/on alternating pressure mode. Air cell will alternate in 10 minute cycles. In static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition. The static mode will help ensure the patient does not bottom out when in a sitting position.
c. During a review of Resident 213’s admission Record (AR), the admission Record indicated Resident 213 was admitted on [DATE] with diagnoses that included pressure ulcers of the sacral region (bottom of the spine) and left buttock.
During a review of Resident 213’s History & Physical (H&P), dated 9/1/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 213’s Care Plan (CP), the CP indicated:
Resident 213 had a stage 4 PU on the sacrococcyx (lower part of the spine and tail bone) extending to the left buttock. The CP listed interventions included to follow treatment as ordered and a goal to heal without complications, dated 10/19/2024.
Resident 213 had a right trochanter (bony prominence of the thigh bone, near the hip bone) PU stage 4 development related to a history of ulcers. The CP indicated a listed intervention to administer treatments as ordered and monitor effectiveness with a goal to heal and have intact skin, dated 6/5/2025.
During a review of Resident 213’s Minimum Data Set assessment (MDS – a federally mandated resident assessment tool), dated 7/14/2025, the MDS indicated Resident 213 had severely impaired cognition (ability to think) and was dependent (helper does all of the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers were required for the resident to complete the activity, to roll left and right or move from sitting to lying. The MDS indicated Resident 213 had two stage 4 PUs (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and an ulcer treatment was a pressure reducing device for the bed.
During a review of Resident 213’s Braden Scale (Braden Scale - assessment tool used to assess a resident’s risk of developing a pressure ulcer) for Predicting Pressure Sore Risk, dated 7/14/2025, the Braden Scale indicated Resident 213 was at high risk for developing a PU.
During a review of Resident 213’s Wound Evaluation and Treatment by the wound healing care specialist, dated 8/15/2025, the wound evaluation and treatment indicated Resident 213 was bedbound and recommendations included aggressive offloading with a low air loss mattress and to follow facility pressure injury prevention/relief protocol for the PUs.
During a review of Resident 213’s Order Summary Report, dated 8/21/2025, the Order Summary indicated Resident 213 had an order for a pressure relieving LAL (low air loss) mattress set to alternating and weight of resident for wound management, every shift, ordered on 1/17/2025.
During a review of Resident 213’s Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 8/1/2025 through 8/31/2025, the MAR indicated Resident 213’s LAL mattress settings were checked three times a day by nursing staff during day, evening, and night.
During an observation on 8/19/2025 at 9:06 am while in Resident 213’s room, Resident 213 was in bed with the LAL mattress on the static mode (a setting that creates a firm surface).
During a concurrent observation and interview on 8/19/2025 at 9:21 am with Licensed Vocational Nurse 2 (LVN 2) while in Resident 213’s room, LVN 2 confirmed the LAL mattress setting was on the static mode. LVN 2 stated Resident 213 had PUs and received wound treatments, but was unaware of what the LAL static setting was used for.
During a concurrent observation and interview on 8/19/2025 at 9:40 am with Treatment Nurse 1 (TN 1), the static light on the LAL mattress was observed on. TN 1 stated Resident 213 was on the LAL mattress for wound management to aid in healing the stage 4 PUs on his sacrococcyx and right hip area. TN 1 stated the LAL mattress was on static setting to make the bed more stable. TN 1 then stated they don’t normally use static and someone must have changed it. TN 1 then turned the static setting off.
During an interview on 8/22/2025 at 10:11 am with the Director of Nursing (DON), the DON stated the LAL mattress wouldn’t serve its purpose if it was not on the appropriate setting to offload the weight. The DON stated the LAL mattress should not be on static mode and should be alternating to avoid a firm surface.
During a review of undated “Proactive Medical Products: Operation Manual for Protekt Aire 2000,” the manual indicated it was for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive PU management program. The manual indicated when in static mode, the static indicator would come on and the overlay provided a firm surface that makes it easier for the resident to transfer or reposition.
During a review of the facility’s policy and procedure (P&P) titled, “Support Surface Guidelines,” last revised 9/2013, the P&P indicated for residents at risk of skin breakdown, redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction.
d. During a review of Resident 136’s admission Record (AR), the AR indicated Resident 136 was admitted to the facility on [DATE] with diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD- is a common lung disease causing restricted airflow and breathing problems), type 2 diabetes (elevated sugar in the blood), pneumonia (is an infection that inflames the air sacs in one or both lungs), morbid obesity (a person's body has a lot of extra weight) with alveolar hypoventilation (is a breathing disorder that affects some people who have obesity).
During a record review of Resident 136’s History and Physical (H&P), dated 7/17/2025, the H&P indicated Resident 136 does has the capacity to understand and make decisions.
During a review of Resident 136’s Care Plan (CP) dated 7/17/2025 indicated, “The resident has a left upper extremity scattered skin discoloration. The listed Interventions indicated LALM for skin maintenance.
During a review of Resident 136’s Minimum Date Set (MDS – a resident assessment tool), dated 7/22/2025, indicated Resident 136 required dependent care (helper does all of the effort, the resident does none of the effort to complete the activity) from staff for toileting hygiene, shower/bathing self and putting on/taking off footwear.
During a review of Resident 136’s Wound Evaluation and Treatment Progress Note dated 8/14/2025 recommendations indicated, “Every 2 hour turning, no sitting beyond 2 hours, frequent diaper checks and changes, keep the skin clean and dry, follow facility pressure injury prevention/relief protocol, low air loss mattress.”
During a review of Resident 136’s Order Summary Report (OSR) dated 8/22/2025 at 4:06 PM, the OSR indicated “Low air loss mattress for skin maintenance. Monitor pressure settings according to patients weight and comfort every shift.”
During a review of Resident 136’s weight documentation dated 8/18/2025, the weight documentation indicated Resident 136’s was 190 lbs. (a common abbreviation for the word pounds (plural), referring to the unit of weight or mass).
e). During a review of Resident 41’s AR, the AR indicated Resident 41 was admitted to the facility on [DATE] with a diagnosis of acute embolism and thrombosis of unspecified deep veins (a new onset blood clot forming in a deep vein, which may also involve a traveling clot) of right lower extremity (right leg) , chronic kidney disease stage 4 (severe damage and are functioning at only 15%-29% of the kidney normal capacity), type 2 diabetes (sugar in the blood), morbid (severe) obesity due to excess calories and generalized edema (fluid retention and swelling that affects the entire body, rather than just one area).
During a review of Resident 41’s H&P dated 7/29/2025, the H&P indicated Resident 41 can make needs known but cannot make medical decisions.
During a review of Resident 41’s Order Summary Report (OSR) dated 7/29/2025, the OSR indicated, “Low air loss mattress for wound management. Monitor pressure settings according to patient’s weight and comfort every shift.
During a review of Resident 41’s MDS dated [DATE], the MDS indicated Resident 41 required dependent care (helper does all of the effort, the resident does none of the effort to complete the activity) from staff for personal and toileting hygiene, shower/bathing self and putting on/taking off footwear and upper body dressing.
During a review of Resident 41’s weight documentation dated 8/20/2025 the weight for Resident 41 was 180.2 lbs.
During an initial observation of Resident 41 on 8/19/2025 at 9:58 AM, Resident 41 was resting in bed on LALM which had a setting of 350+ lbs.
During an initial observation of Resident 136 on 8/19/2025 at 11:03 AM, Resident 136 was resting in bed on LALM which had a setting of 350+ lbs.
During an interview with Registered Nurse Supervisor (RN5) on 8/21/2025 at 9:11 AM, RN5 stated that for residents on a LALM, the settings are determined by the residents' weight. Per RN5 all license nurses must check the settings on the LALM every shift when they are doing their initial assessments to make sure the settings are correct by residents weight. RN5 stated that the purpose of the LALM is to prevent and assist in pressure ulcer development. Per RN5, if the LALM is too firm, it might cause the resident to actually develop a pressure injury or pressure ulcer. RN5 stated “If the settings aren’t set to the resident's weight, it defeats the purpose of having the LALM instead of preventing a pressure ulcer it can cause more harm than good by causing a pressure ulcer.”
During an interview with the IPN on 8/21/2025 at 3:03 PM, the IPN stated the settings are according to the doctor’s order. We have placed little stickers to show depending on their weight. The CN should see if it’s on the right setting every shift and the cnas need to be vigilant they don’t move the settings on accident.
During an interview with the DON on 8/22/2025 at 9:07 AM, the DON stated the settings for a LALM needs to be according to the resident's weight. Per the DON, if the settings aren’t correct, it doesn't serve the purpose to promote wound healing. The DON stated the purpose of a LALM is to prevent and treat pressure ulcers by redistributing pressure and managing moisture on the resident's skin.
During an interview with TN1 on 8/22/2025 at 1:33 PM, TN1 stated the LALM settings are supposed to be per resident's body weight. Per TN1, if the LALM is too firm, it will not help promote wound healing and can cause more harm than good. TN1 stated the mattress is supposed to distribute weight and maintain airflow to prevent bedsores by reducing pressure on bony prominences (areas of the body where bones are close to the skin's surface) which are areas at a higher risk for residents of developing pressure ulcers.
During an interview and record review with Medical Record (MR) staff on 8/22/2025 at 3:38 PM, the MR confirmed that there is no specific care plan for LALM for Resident 41. The MR stated if any resident was on LALM, there should have been a care plan including interventions in the residents' medical records.
During a record review of the facilities LALM operational manual titles, “Proactive medical products” the operational manual indicated, “Protekt Aire 3000 pump and mattress system, is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program.” Operating instructions indicate to determine the patient’s weight and set the control knob to that weight setting on the control unit.
During a review of the facilities P&P titled, “Quality of Life-Dignity” revised February 2020 indicated, “Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.” Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example, promptly responding to a resident’s request for toileting assistance.
During a review of the facilities P&P titled, “Accommodation of Needs” revised March 2021, the P&P indicated, “Our facility’s environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being.”
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary care and services for residents on ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary care and services for residents on oxygen therapy (treatment that provides supplemental, or extra oxygen) in accordance with the facility's Policy and Procedure (P&P) on Oxygen Administration for three of four sampled residents (Residents 9, 25, and 122).These failures had the potential for Residents 9, 25, and 122 to result in respiratory complications and infections. Findings:
a. During a review of Resident 9’s admission Record (AR), the admission Record indicated Resident 9 was admitted on [DATE] with diagnoses that included respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide from the lungs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and heart failure (when the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen).
During a review of Resident 9’s Care Plan (CP), dated 1/18/2025, the CP indicated, Resident 9 had COPD and the goal indicated Resident 9 would remain free of signs and symptoms of respiratory infections.
During a review of Resident 9’s History & Physical (H&P), dated 5/12/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 9’s Minimum Data Set assessment (MDS – a federally mandated resident assessment tool), dated 7/14/2025, the MDS indicated Resident 9 had moderately impaired cognition (ability to think).
During a review of Resident 9’s Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 8/1/2025 through 8/31/2025, the MAR indicated Resident 9 may be given oxygen at 2-3 liters per minute (lpm) via NC to keep the oxygen saturation greater than 93% for shortness of breath. The MAR indicated, Resident 9’s oxygen saturation was documented during day, evening, and night.
During a concurrent observation and interview on 8/19/25 at 9:04 am with Licensed Vocational Nurse 2 (LVN 2) while in Resident 9’s room, Resident 9 was receiving oxygen through a nasal cannula labeled 8/4/2025 with the oxygen tubing touching the floor. LVN 2 stated Resident 9’s oxygen tubing should not be touching the floor because it could contaminate her equipment. LVN 2 stated the oxygen tubing was changed weekly to prevent the resident from getting an infection and if it was over a week, it should be changed and new.
During an interview on 8/22/2025 at 12:05 pm with the Director of Nursing (DON), the DON stated the oxygen tubing should not be touching the floor when in use and was changed once every week on Sunday. The DON stated it was done for infection prevention and control for the resident.
During a review of the facility’s policy and procedure (P&P) titled “Departmental (Respiratory Therapy)-Prevention of Infection,” last revised November 2011, the P&P indicated it’s purpose was to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. The P&P indicated, to review the resident’s care plan to assess for any special circumstances or precautions related to the resident. The oxygen cannula and tubing be changed every seven days or as needed for infection control.
During a review of the facility’s policy and procedure (P&P) titled, “Oxygen Administration,” last revised October 2010, the P&P indicated for nursing to verify that there was a physician order or facility protocol for oxygen administration and that “No Smoking/Oxygen in Use” signs were outside of the room entrance door and in a designated place on or over the resident’s bed.
b. During a review of Resident 25’s admission Record (AR), the AR indicated Resident 25 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included congestive heart failure (CHF, a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling), dyspnea (difficulty breathing), and pulmonary embolism (medical condition where a blood clot travels from another part of the body, usually the legs and blocks an artery in the lungs).
During a review of Resident 25’s Order Summary Report (OSR), dated 7/6/2024, the OSR indicated Resident 25 had an order for oxygen at 2-4 liters (L, unit of volume) via nasal cannula (NC, a thin, flexible tube which on one end splits inti two prongs which are placed in the nostrils to deliver oxygen).
During a review of Resident 25’s Minimum Data Set (MDS, a resident assessment tool), dated 8/9/2025, the MDS indicated Resident 25 had intact cognition (ability to understand and process information). The MDS indicated Resident 25 required partial/moderate assistance (helper did less than half the effort) with toileting, shower, upper body dressing and required substantial/maximal assistance (helper did more than half the effort) with lower body dressing and personal hygiene.
During a concurrent observation inside Resident 25’s room and interview on 8/19/2025 at 9:14 am with Certified Nurse Assistant 3 (CNA 3), Resident 25 was in bed with oxygen at 4 L/NC. CNA 3 stated nasal cannula tubing was not labeled with the date when it was changed. CNA 3 stated there was no cautionary sign of “no smoking/oxygen in use” posted outside Resident 25’s room. CNA 3 stated the cautionary sign outside the room reminded staff, visitors and other residents that a resident was on oxygen and a potential risk for fire.
During a concurrent interview and record review on 8/22/2025 at 9:42 am with Registered Nurse Supervisor 2 (RN 2), Resident 25’s care plans were reviewed. RN 2 stated Resident 25 did not have a care plan developed to address the resident’s chronic (long-time) use of oxygen and for the staff to know the interventions specific for the resident.
c. During a review of Resident 122’s AR, the AR indicated Resident 122 was admitted to the facility on [DATE] with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms, usually from a spinal cord injury), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing).
During a review of Resident 122’s MDS, dated [DATE], the MDS indicated Resident 122 had intact cognition. The MDS indicated Resident 122 required partial/moderate assistance with oral hygiene and dependent (helper did all the effort, resident did none of the effort to complete the activity) with toileting, shower, upper and lower body dressing and personal hygiene.
During a review of Resident 122’s Order Summary Report (OSR), dated 8/11/2025, the OSR indicated Resident 122 had an order for oxygen at 2-4 liters per minute via nasal cannula.
During a concurrent observation inside Resident 122’s room and interview on 8/19/2025 at 9:48 am with CNA 1, Resident 122 was in bed with oxygen at 3.5 L via NC. CNA 1 stated nasal cannula tubing was not labeled with the date when it was changed. CNA 1 stated there was no cautionary sign of “no smoking/oxygen in use” posted outside Resident 122’s room. CNA 1 stated the cautionary sign outside the room was necessary for fire precautions.
During an interview on 8/22/2025 at 9:42 am with RN 2, RN 2 stated all residents on oxygen therapy should have the oxygen tubing change weekly and as needed and labeled with the date when it was changed to make sure that oxygen tubing was changed to keep it clean and prevent infection. RN 2 stated all residents on oxygen therapy should have a “no smoking/oxygen in use” sign posted outside the residents’ room for the safety of the residents and staff in the facility.
During an interview on 8/22/2025 at 12:05 pm with the Director of Nursing (DON), the DON stated all residents’ oxygen tubing should be labeled with date to know when it was changed and due to be changed to prevent the spread of infections. The DON stated all residents on oxygen therapy should have a “no smoking/oxygen in use” sign posted outside the residents’ rooms to alert the staff, visitors and residents that oxygen was present in the room for the safety of everyone in the facility. The DON stated all residents on oxygen therapy should have a care plan developed to assist and guide the staff on how to provide care and treatment to the residents.
During a review of the facility’s policy and procedures (P&P) titled, “Oxygen Administration,” revised October 2010, the P&P indicated, “Review the resident’s care plan to assess for any special needs of the resident. Place a “No Smoking/Oxygen In Use” sign on the outside of the room entrance door.”
During a review of the facility’s P&P titled, “Departmental (Respiratory Therapy)-Prevention of Infection,” revised November 2011, the P&P indicated, “Change the oxygen cannula and tubing every seven days, or as needed.”
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
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 residents on hemodialysis (a treatment to cle...
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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 residents on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) an emergency kit (E-kit, contains the main items needed in an emergency) at the bedside for two of six sampled residents (Residents 111 and 219) in accordance with the residents' comprehensive care plan.These failures had the potential for Residents 111 and 219 not to receive or receive delayed care and emergency treatment from complications caused by unexpected bleeding from the hemodialysis access site. Findings:a. During a review of Resident 111's admission Record (AR), the AR indicated Resident 111 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure), congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control).During a review of Resident 111's untitled Care Plan (CP) dated 10/2/2024, the CP indicated Resident 111 had the potential for bleeding on the site with hemodialysis access. The CP interventions and goals included to place a [NAME] clamp (a type of surgical hemostat used to clamp and control bleeding from blood vessels or tissue during surgery and emergency procedures) at bedside for management of emergency bleeding on central line access site and emergency bleeding will be managed with immediate implementation of appropriate interventions.During a review of Resident 111's Minimum Data Set (MDS, a resident assessment tool) dated 6/26/2025, the MDS indicated Resident 111 had moderately impaired cognition (ability to understand and process interventions). The MDS indicated Resident 111 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from staff with toileting, upper and lower body dressing. The MDS indicated Resident 111 required partial/moderate assistance (helper did less than half the effort) from staff with shower and personal hygiene.During a review of Resident 111's Order Summary Report (OSR) dated 7/9/2025, the OSR indicated Resident 111 had a tunneled catheter (a thin, flexible tube that is inserted into a vein and tunneled under the skin) hemodialysis access site on the right upper chest. The OSR indicated Resident 111 was scheduled for hemodialysis every Tuesdays, Thursdays, and Saturdays. During a concurrent observation and interview on 8/19/2025 at 10:00 am with Certified Nurse Assistant 1 (CNA 1), Resident 111 was lying in bed with hemodialysis access site on the right chest. CNA 1 stated Resident 111 did not have an E-kit at bedside. CNA 1 stated Resident 111 needed to have an E-kit at bedside for use in case of bleeding from the dialysis access site.b. During a review of Resident 219's AR, the AR indicated Resident 219 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included ESRD, anemia (a condition where the body does not have enough healthy red blood cells), and dependence on hemodialysis.During a review of Resident 219's MDS dated [DATE], the MDS indicated Resident 219 had severely impaired cognition. The MDS indicated Resident 219 was dependent (helper did all the effort) from staff with oral hygiene, toileting, shower, upper and lower body dressing.During a review of Resident 219's OSR dated 7/29/2025, the OSR indicated Resident 219 had a quinton catheter (non-tunneled catheter, large-bore, dual-lumen central venous catheter used to provide immediate temporary access for hemodialysis) hemodialysis access site on the left upper thigh. The OSR indicated Resident 219 was scheduled for hemodialysis every Mondays, Wednesdays, and Fridays.During a review of Resident 219's CP dated 8/7/2025, the CP indicated Resident 219 had the potential for bleeding from the central line site related to hemodialysis. The CP interventions included to place [NAME] clamp at bedside for management of emergency bleeding on the central line access site.During a concurrent observation and interview on 8/19/2025 at 9:18 am with CNA 3, Resident 219 was lying in bed with hemodialysis access site on the left upper thigh. CNA 3 stated Resident 219 did not have an E-kit at bedside. CNA 3 stated Resident 219 should have an E-kit at bedside to use in case of emergency like bleeding from the hemodialysis access siteDuring an interview on 8/21/2025 at 11:54 am with the facility's Director of Nursing (DON), the DON stated all hemodialysis residents needed to have an E-kit at bedside, close and easily accessible to the staff to use to stop and control if bleeding occurs from the hemodialysis access site. During a review of the facility's Policy and Procedure (P&P) titled, End-Stage Renal Disease, Care of a Resident With, revised September 2010, the P&P indicated, How to recognize and intervene in medical emergencies such as hemorrhage and septic infection. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient staffing, resulting in toileting and/or incontin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient staffing, resulting in toileting and/or incontinent care not being provided for two of three sampled residents (Residents 11 and 136) in a timely manner. This failure had the potential to result in Residents 11and 136 experiencing skin breakdown and/or placing the residents at risk of experiencing a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). (Cross Reference F550)
Findings:
a. During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood).
During a review of Resident 11’s History and Physical (H&P), dated 6/7/2025, the H&P indicated Resident 11 had the capacity to understand and make medical decisions.
During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool) dated 8/5/2025, the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 11 was dependent (helper does all the effort) on staff for bathing, dressing, and toileting hygiene.
During an interview on 8/19/2025 at 1:29 PM with Resident 11, Resident 11 stated Resident 11 had to sometimes wait a long time for help from nurses (in general). Resident 11 stated Resident 11 pressed the call light earlier in the morning of 8/19/2025 because Resident 11 needed Resident 11’s diaper changed. Resident 11 stated Resident 11 waited so long that Resident 11 fell asleep.
During a Resident Council Meeting on 8/20/2025 at 1:54 PM, four of the eight residents present indicated the residents had to wait “too long” for assistance from facility staff when the residents pressed their call lights.
During an interview on 8/21/2023 at 9:23 AM with Registered Nurse 4(RN 4), RN 4 stated Station 1 was one of the heavier stations regarding caring for residents (in general). RN 4 stated it would be beneficial if Station 1 had another CNA in addition to the three CNAs already assigned. RN 1 stated call lights would be answered faster if Station 1 had an additional CNA. RN 4 stated residents (in general) and family members (in general) complained to RN 4 about waiting too long for call light responses from the staff (in general).
During a concurrent interview and record review on 8/21/2025 at 2:24 PM with Activities Director 1 (AD 1), the facility’s “Resident Council Minutes (RCM),” dated 5/20/2025, 6/17/2025, 7/15/2025, and 7/30/2025 were reviewed. Each of the “RCM” documents indicated facility staff (in general) were not answering call lights in a timely manner. AD 1 confirmed that some of the residents (in general) who attended the monthly Resident Council Meeting had been complaining regularly about staff (in general) not answering call lights promptly for the past six months.
During an interview on 8/22/2025 at 8:34 AM with CNA 5, CNA 5 stated facility staff (in general) should respond to residents’ call lights immediately. CNA 5 stated CNA 5 worked in CNA 5’s assigned unit of Station 1. CNA 5 stated CNA 5 usually was assigned to care for 10 residents during CNA 5’s shift (7AM – 3 PM). CNA 5 stated it was hard to provide care to residents (in general) in a timely manner because Station 1 only had three CNAs. CNA 5 stated a resident (unidentified) was frustrated with CNA 5 on 8/19/2025 because the unidentified resident waited 10 minutes for CNA 5 to change the unidentified resident’s soiled diaper.
During an interview on 8/22/2025 at 8:47 AM with CNA 6, CNA 6 stated CNA 6 usually worked in Station 1. CNA 6 stated Station 1 only had three CNAs assigned to Station 1 during the morning shift (7 AM – 3 PM). CNA 6 stated the residents (in general) in Station 1 required a lot of care. CNA 6 stated that sometimes CNA 6 only had time to change soiled diapers for incontinent residents (in general) once during the entire shift. CNA 6 stated CNA 6 often was assigned to care for Resident 11. CNA 6 stated it sometimes took CNA 6, 20 minutes to respond to Resident 11’s request to change Resident 11’s soiled diaper because CNA 6 was busy caring for other residents (in general) in Station 1.
During a concurrent interview and record review on 8/22/2025 at 11:52 AM with the Director of Staff Development (DSD), the facility’s “Station 1 C.N.A. Assignment Sheet(s) (AS),” dated 8/4/2025 to 8/18/2025 were reviewed. The “AS(s)” dated 8/4/2025 to 8/9/2025 and 8/15/2025 to 8/18/2025 indicated CNA’s (in general) were assigned to care for 10 residents during the 7AM – 3 PM shift. The DSD stated CNAs should be assigned to care for 8-9 residents (in general) during the 7 AM – 3 PM shift. The DSD stated if the CNA’s (in general) were assigned 10 residents then the delivery of care to the residents would be delayed.
During a review of the facility's Facility Assessment, titled, “HSAG-File--Facility Assessment Tool,” undated, the facility assessment indicated the facility’s staffing plan included that CNAs would be assigned to care for 8-9 residents during the 7 AM – 3 PM shift.
During a review of the facility's Policy and Procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, revised August 2022, the P&P indicated, the facility provides sufficient numbers of nursing staff … to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The P&P indicated staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment.
During a review of the facility's P&P titled, Answering the Call Light, revised September 2022, the P&P indicated, “Answer the resident call system immediately.”
b. During a review of Resident 136’s AR, the AR indicated Resident 136 was admitted to the facility on [DATE] with diagnoses that included COPD, pneumonia (an infection that inflames one or both lungs) and morbid obesity (a person's body has a lot of extra weight).
During a record review of Resident 136’s H&P dated 7/17/2025, the H&P indicated Resident 136 had the capacity to understand and make decisions.
During a review of Resident 136’s MDS dated [DATE], the MDS indicated Resident 136 was dependent care (helper does all of the effort, the resident does no effort to complete the activity) from staff for toileting hygiene, shower/bathing self and putting on/taking off footwear.
During a review of Resident 136’s Skin Check (SC) dated 7/17/2025, the SC indicated Resident 136 had a skin issue in the middle area of the sacrum (a triangular bone at the base of the lower back) that was present on admission considered a pressure ulcer/injury (damage to the skin caused by continuous pressure) Stage 3 full-thickness skin loss (a bedsore where the skin is destroyed and extending into deeper tissue and fat) and surrounding tissue to be fragile with skin that was at risk for breakdown. The SC indicated additional care areas for incontinence management and mattress with pump.
During a review of Resident 136’s untitled Care Plan (CP) dated 7/17/2025, the CP indicated Resident 136 had Activities of Daily Living (ADL) decline and potential for skin breakdown. The CP goal was to prevent skin breakdown. There were no ADL maintenance or repositioning included or documented in any other CP in Resident 136’s medical record (MR).
During a review of Resident 136’s Wound Evaluation & Treatment Progress Note (WETPN) dated 8/14/2025, the WETPN indicated Resident 136’s sacrococcyx (the tail bone located at the base of the spine), sacral region (lower back) wound was closed. The WETPN indicated recommendations including aggressive offloading (refers to the practice of relieving or redistributing pressure from a specific area of a resident's body to prevent and treat wounds, especially pressure ulcers), every two hours turning, no sitting beyond 2 hours and frequent diaper checks and changes. The WETPN indicated additional recommendations to turn Resident 136 every two hours and to keep the skin clean and dry.
During an observation and interview with Resident 136 on 8/19/2025 at 11:03 AM, Resident 136 was sitting up in bed watching television (TV). Resident 136 stated, “I’ve had a bowel movement (BM) since 7:30 AM. I've been calling them (staff) and it’s 11:03 AM now and I'm still waiting. I’m afraid my wounds will come back. I am very upset and embarrassed. Sometimes I wait up to three hours to get cleaned up. I called and they(staff) do not come.”
During an interview with Licensed Vocational Nurse 9 (LVN 9) on 8/19/2025 at 11:11 AM, LVN 9 stated Resident 136 should not have been waiting since 7:30 AM to be cleaned by staff especially if Resident 136 had a bowel movement. LVN 9 stated it was not sanitary and uncomfortable for Resident 136 to be soiled for a long period of time. LVN 9 stated CNA 4 was assigned to care for Resident 136, but CNA 4 was busy with another resident.
During an interview with CNA 4 on 8/19/2025 at 11:14 AM, CNA 4 stated there were 10 residents assigned to CNA 4 for the day (8/19/2025) and someone (unidentified) could have answered the call light earlier and not communicated to CNA 4 that Resident 136 was soiled and needed to be changed. CNA 4 stated CNA 4 was busy earlier because there was a room change.
During an interview with LVN 10 on 8/20/2025 at 11:56 AM, LVN 10 stated residents should get peri-care (cleaning of the area between the anus and genitals) often for hygiene and to prevent infections and skin problems. LVN 10 stated it was not acceptable to have a resident sitting in their own bowel movement for long periods of time as this could make them feel terrible, helpless, neglected and sad, putting the resident at risk for depression or anxiety.
During an interview with the Infection Prevention Nurse (IPN) on 8/21/2025 at 3:10pm, the IPN stated every resident needed to be provided with peri-care as needed. The IPN stated it was not acceptable to leave a resident for long periods of time if they are soiled and if a resident was not cared for in a timely manner, it would make the resident feel uncomfortable, embarrassed and neglected, resulting in lowered self-esteem and feeling depressed. The IPN stated a resident that was left in “soiled conditions” for extended periods of time could have serious infection risks, skin breakdown and bedsores. The IPN stated the combination of moisture and bacteria from urine and feces would create an environment that can quickly lead to skin breakdown, infection and other health complications.
During an interview with the DON (DON) on 8/22/2025 at 9:10 AM, the DON stated it was not acceptable for a resident to be in bed soiled for hours. The DON stated, as soon as a staff identify the resident needed to be changed, the resident needed to be cleaned immediately.
During an interview with the Treatment Nurse (TN1) on 8/22/2025 at 1:33 PM, TN1 stated ADLs and timely peri-care must be provided to all residents. TN 1 stated, when residents were at risk of skin breakdown or have wounds, it was extremely important to prevent infections. TN 1 stated it was not acceptable for a resident to be soiled from 7:00 AM to 11:00 AM. TN1 stated, if a resident was left for long periods of time soiled or not being cleaned, it would make the resident feel uncomfortable, embarrassed and neglected.
During a review of the facility’s Policy and Procedures (P&Ps) titled, “Activities of Daily Living (ADL), Supporting” revised March 2018, the P&P indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The P&P indicated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
During a review of the facility’s P&P titled, “Perineal Care”, revised February 2018, the P&P indicated, “The purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident’s skin conditions.”
During a review of the facility’s P&P titled, “Residents Rights”, revised December 2016, the P&P indicated, “Employees shall treat all residents with kindness, respect and dignity.”
During a review of the facility’s P&P titled, “Quality of Life-Dignity”, revised February 2020, the P&P indicated, “Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.” The P&P indicated demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents. For example, promptly responding to a resident’s request for toileting assistance.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to:a. Administer medications in a timely manner for three ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to:a. Administer medications in a timely manner for three of four sampled residents (Residents 218, 209 and 89). This failure had the potential to result in the effectiveness of the medication affecting the residents' wellbeing.b. Ensure during a medication pass observation on 8/21/2025 at 8:33 am, Licensed Vocational Nurse 8 (LVN 8) did not attempt to administer 2 tablets of Tylenol Oral Tablet 325 mg to Resident 34.c. Ensure an accurate account of the use of a controlled medication (medications that the use and possession of are controlled by the federal government), Pregabalin (a controlled medication used for pain and seizures) for Resident 47 when the licensed nurse did not document its usage on the controlled drug record.These deficient practices had the potential to result in adverse consequences for the residents. Findings:
a. A review of Resident 218’s admission Record (AR), dated 10/19/2024, the AR indicated that Resident 218 has iron deficiency anemia due to chronic blood loss, a Stage IV Pressure (a localized area of skin damage that develops due to prolonged pressure on an area of the body) Ulcer of Sacral Region, Type 2 diabetes, and intractable epilepsy.
A review of Resident 218’s Care Plan Report (CP), dated 10/19/2024, the CP indicated that Resident 218 should have medications administered as ordered and be monitored for side effects of those medications for diabetes, anemia, seizures, a pressure ulcer and report those side effects to the physician.
A review of Resident 89’s admission Record (AR), dated 4/21/2025, the AR indicated Resident 89 has end stage renal (Kidney) disease, anemia, and hyperlipidemia (high levels of cholesterol in the blood).
A review of Resident 89’s Care Plan Report (CP), dated 4/22/2025, the CP indicated that Resident 89’s anemia (not having enough red blood cells) medication should be given as ordered and the goal for Resident 89 was to remain free of complications related to hyperlipidemia and administer fenofibrate tab 145 mg tablet and ezetimibe tab 10mg one time a day.
A review of Resident 218’s Minimum Data Set Assessment (MDS), dated [DATE], the MDS indicated that Resident 218 has a problem remembering the past and Resident 218’s skills for daily decision making are severely impaired.
A review of Resident 209’s admission Record (AR), dated 7/10/2025, the AR indicated that Resident 209 had a Stage 2 pressure ulcer, epilepsy, and hereditary and idiopathic neuropathy.
A review of Resident 209’s Care Plan Report (CP), dated 7/10/2025, the CP indicated that Resident 209’s pain medications should be given as order by the physician.
A review of Resident 209’s Minimum Data Set Assessment (MDS), dated [DATE], the MDS indicated Resident 209 is absent of spoken words, is rarely understood, and is severely impaired at making decisions.
During an interview on 8/22/2025 at 9:54 a.m., with LVN 13, LVN 13 stated medications are late if given two hours after the assigned time. Residents can experience side effects from not having the medication on time. We notify the families when the medications are late.
During an interview on 8/22/2025 at 9:58 a.m., with RN 1, RN 1 stated medications are late if given one hour after the medication is due and the Physician or Nurse Practitioner are notified. If medications are given late the resident’s blood pressure or heart rate could be affected. Also, the medication levels in the blood are affected.
A review of Resident 218’s Medication Administration Audit Report (MAAR), dated 8/22/2025, the MAAR indicated that the following medications were administered greater than one hour after the prescribed administration time:
1.SF Prostat 30cc PO Daily for 3 months – Healing Support in the morning until 9/19/2025 at 23:59, prescribed for 9 a.m., every day, was administered more than one hour after the prescribed administration time on the following dates: 8/4/2025 administered at 10:22 a.m.; 8/5/2025 administered at 10:58 a.m.; and on 8/9/2025 administered at 10:46 a.m.
2.Levetiracetam oral solution 100mg. Give 5 mL enterally every 12 hours for seizure (uncontrollable jerking body movement) disorder, prescribed for 9 a.m. was administered more than one hour after the prescribed administration time on the following dates: 8/4/2025 at 10:22 a.m.; on 8/5/2025 at 10:58 a.m.; and on 8/6/2025 at 11:41 a.m.
3.Ferrous Sulfate Elixir 220 mg solution; give 7.5 cc enterally one time a day for anemia, prescribed for 9 a.m. was administered more than one hour after the prescribed administration time on the following dates: 8/4/2025 at 10:22 a.m.; on 8/5/2025 at 10:58 a.m.; and on 8/6/2025 at 11:41 a.m.
A review of Resident 209’s Medication Administration Audit Report (MAAR), dated 8/22/2025, the MAAR indicated that the following medications were administered greater than one hour after the prescribed administration time:
1.Gabapentin Oral Tablet 100 mg; give one capsule via G-tube three times a day for neuropathy, were more than one hour past the prescribed medication time for two morning doses, due at 9 a.m., and one afternoon dose, due at 1 p.m. The following dates and times are: 8/1/2025 at 3:20 p.m., 8/2/2025 at 3:38 p.m., and at 8/4/2025 at 10:20 a.m.
2. Levetiracetam Oral Tablet 500mg; give 1 tablet via G-Tube two times a day for seizures, were more than one hour past the prescribed medication time of 9:00 a.m. for three doses on the following dates and times are: 8/3/2025 at 11:05 a.m.; 8/5/2025 at 10:57 a.m., and 8/6/2025 at 11:41 a.m.
3. Zinc Sulfate Oral Tablet 66mg. Give one tablet via G-Tube one time a day for healing support was more than one hour past the prescribed medication time of 9 a.m. for three doses on the following dates and time: 8/5/2025 at 10:55 a.m.; 8/6/2025 at 11:41; and 8/9/2025 at 10:48 a.m.
A review of Resident 89’s Medication Administration Audit Report (MAAR), dated 8/22/2025, the MAAR indicated that the following medications were administered greater than one hour after the prescribed administration time:
1.B-Complex w/ C & Folic Acid Tablet 0.8 mg. Give 1 tablet by mouth one time a day for supplement prescribed for administration at 11 a.m. was administered more than one hour after the prescribed administration time on 8/3/2025, 8/4/2025, and 8/6/2025.
2. Fenofibrate tablet 145 mg. Give 1 tablet by mouth one time a day for hyperlipidemia prescribed for administration at 11 a.m. was administered more than one hour after the prescribed administration time on 8/3/2025, 8/4/2025, and 8/5/2025.
3. Ezetimibe tablet 10 mg. Give one tablet by mouth one time a day for hypercholesterolemia was administered more than one hour after the prescribed administration time on 8/4/2025, 8/5/2025, and 8/6/2025.
A review of the facility’s policy and procedure titled, Administering Medications, dated April 2019, the policy indicated medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
b. During a review of Resident 34’s admission Record (AR), the AR indicated Resident 34 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure (condition characterized by a gradual loss of kidney function over time) and heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs).
During a review of Resident 34's Order Summary Report (OSR), dated 6/30/2025, the OSR indicated to administer Tylenol (Acetaminophen, medicine that relieves mild to moderate pain and reduces fever) Oral Tablet 325 milligrams (mg, unit of measurement), two (2) tablet by mouth in the morning for pain. Give 30 minutes prior (before) to wound care, not to exceed (NTE) three (3) grams (gr, unit of measurement) in 24 hours.
During a review of Resident 34’s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 7/15/2025, the MDS indicated Resident 34 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 34 was dependent (helper does all of the effort) to staff for toileting hygiene and shower. The MDS indicated Resident 34 needed maximum assistance (helper did more than half the effort and lifted or held trunk or limbs) to staff for upper/lower body dressing, putting on/taking off footwear and personal hygiene.
During a medication pass observation on 8/21/2025 at 8:33 am, Licensed Vocational Nurse 8 (LVN 8) attempted to administer 2 tablets of Tylenol Oral Tablet 325 mg prior to wound care to Resident 34.
During an interview on 8/21/2025 at 8:34 am, Resident 34 stated “I don’t have any wound. I don’t want to take Tylenol.”
During an interview on 8/21/2025 at 9:30 am, with LVN 8, the LVN 8 stated, “Tylenol was discontinued now (8/21/2022) because patient (resident) doesn’t have any wound. Patient’s wound was resolved.”
During an interview with the facility’s Director of Nursing (DON) on 8/21/2025 at 10:08 am, the facility DON stated, Resident 34 did not need Tylenol Oral Tablet routinely because Resident 34’s wound treatment was resolved. The DON stated Tylenol Oral Tablet was ordered to administer prior to wound care and Resident 34 did not have any wounds.
During a concurrent review of Resident 34’s Skin Observation Tool (SOT) dated 8/15/2025, and interview with the Registered Nurse 2 on 8/21/2025 at 2:05 pm, the SOT indicated Resident 34 was seen and evaluated by the wound consultant and had an order to discontinue treatment to the left anterior (front) lower leg wound. RN 2 stated the wound treatment was discontinued by the wound consultant on 8/15/2025. RN 2 stated Resident 34’s wound was resolved.
During a concurrent review of Resident 34's Medication Administration Record (MAR) dated from 8/1/2025 to 8/31/2025, and interview with RN 2 on 8/21/2025 at 2:07 pm, the MAR indicated Resident 34 received Tylenol Oral tablet 325 mg, 2 tablet by mouth in the morning for pain and give 30 minutes prior to wound care from 8/16/2025 to 8/20/2025. The MAR indicated on 8/21/2025 Resident 34 refused to take Tylenol oral tablet. RN 2 stated Tylenol Oral tablet 325 mg should have not administered since 8/16/2025 because the wound was resolved on 8/15/2025. RN 2 stated Resident 34 was receiving unnecessary medication for there was no existing wound or treatment to be done.
During a review of the facility’s policy and procedure (P&P) titled, “Administering Medication, revised 12/2012, the P&P indicated medications shall be administered in a safe and timely manner, and as prescribed. The P&P indicated medications must be administered in accordance with the orders, including any required time frame.
c. During a review of Resident 47’s admission Record (AR), the admission Record indicated Resident 47 was admitted on [DATE] with diagnoses that included alcoholic cirrhosis (chronic liver disease from excessive alcohol consumption), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and insomnia (trouble falling asleep or staying asleep).
During a review of Resident 47’s History & Physical (H&P), dated 1/31/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 47’s Minimum Data Set assessment (MDS – a federally mandated resident assessment tool), dated 7/5/2025, the MDS indicated Resident 47 had intact cognition (ability to think).
During a review of Resident 47’s Order Summary Report, dated 8/22/2025, the Order Summary indicated Resident 47 had an order for Lyrica (generic medication – Pregabalin) oral capsule 100 milligrams (mg) to be given three times a day for pain, ordered on 7/23/2025.
During a review of Resident 47’s Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 8/1/2025 through 8/31/2025, the MAR indicated Resident 47 received Pregabalin oral capsule 100 mg on 8/21/2025 at 9 am and 1 pm.
During a review of Resident 47’s Record of Controlled Substances (a controlled drug record/accountability record of medications that are considered to have a strong potential for abuse) for Pregabalin 100 mg caps, dated 8/3 and ending on 8/20, the record indicated there was no documentation for the doses given on 8/21/2025 at 9 am and 1 pm.
During an interview on 8/21/2025 at 3:25 pm with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated Resident 47 was given Pregabalin 100 mg by her at 8:40 am and 1 pm, but did not document on the Record of Controlled Substances because she was too busy. LVN 7 stated she was supposed to document the administration on the Record of Controlled Substances after Resident 47 took it to prevent any mistakes from happening. LVN 7 stated the medication was an opioid (a class of drug used to reduce moderate to severe pain that can be addictive) for pain and could pose a danger to the resident.
During an interview on 8/22/2025 at 11:58 am with the Director of Nursing (DON), the DON stated when giving a controlled drug the nurse should document it on the MAR and they must sign the controlled drug record to keep count of the quantity remaining and reflect the date/time of when the drug was given. The DON stated, once the medication is removed from the medication blister pack it should be documented timely to avoid it being forgotten. The DON stated signing off on the record was important so every medication that was used had a record and the next shift would know when it was utilized.
During a review of the facility’s policy and procedure (P&P) titled, “Controlled Substances,” last revised 11/2022, the P&P indicated the facility complied with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). The P&P indicated controlled substance inventory were monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The P&P indicated the system of reconciling the receipt, dispensing and disposition of controlled substances included medication administration records.
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 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 provide safe storage of medications by failing to: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 provide safe storage of medications by failing to:a. Ensure Resident 15's eye drop bottle was labeled with the resident's name.b. Ensure Resident 71's eye drop bottle and box were labeled with the resident's name. c. Ensure the medication cart was not left open and unattended and outside of view of staff in nursing station 1.These deficient practices had the potential to result in unintentional medication administration to the wrong resident and could have also resulted in missing medications from the medication cart. Findings:
a. During a review of Resident 15’s admission Record (AR), the admission Record indicated Resident 15 was admitted on [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunction caused by diseases or toxins in the body) and sepsis (a life-threatening blood infection).
During a review of Resident 15’s History & Physical (H&P), dated 6/26/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 15’s Minimum Data Set assessment (MDS – a federally mandated resident assessment tool), dated 7/26/2025, the MDS indicated Resident 15 had moderately impaired cognition (ability to think).
During a review of Resident 15’s Order Summary Report, dated 8/22/2025, the Order Summary indicated Resident 15 had an order for to instill artificial tears ophthalmic solution 1.4% (polyvinyl alcohol) with one drop in both eyes twice a day for dry eyes, ordered on 6/25/2025.
During a review of Resident 15’s Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 8/1/2025 through 8/31/2025, the MAR indicated Resident 15’s received artificial tears ophthalmic solution 1.4% (polyvinyl alcohol) from 8/1/2025 to 8/20/2025 at 9 am and 6 pm and on 8/21/2025 at 9 am.
During a concurrent observation and interview during a medication cart inspection on 8/19/2025 at 3 pm with Licensed Vocational Nurse 7 (LVN 7), an open box of Polyvinyl alcohol 1.4% lubricating eye drops had Resident 15’s medication label on the box and the eye drop bottle lacked any resident identifying information. LVN 7 stated, the eye drop medication should be labeled by the nurse with the resident’s name to prevent giving the medication to another resident.
During an interview on 8/22/2025 at 11:54 am with the Director of Nursing (DON), the DON stated eye drops should be labeled upon opening with the date to allow nurses to know when to replenish it. The DON stated it must be labeled with the resident’s name and the room number on the bottle and the box, but must be labeled on the bottle to prevent another resident from being given the medication.
During a review of the facility’s policy and procedure (P&P) titled, “Medication Labeling and Storage,” last revised 2/2023, the P&P indicated the labeling of medications and biologicals dispensed by the pharmacy were consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The P&P indicated the medication label included at a minimum the resident’s name.
b. During a review of Resident 71’s admission Record (AR), the admission Record indicated Resident 71 was admitted on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and sepsis (a life-threatening blood infection).
During a review of Resident 71’s Minimum Data Set assessment (MDS – a federally mandated resident assessment tool), dated 7/26/2025, the MDS indicated Resident 71 had moderately impaired cognition (ability to think).
During a review of Resident 71’s History & Physical (H&P), dated 7/31/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 71’s Order Summary Report, dated 8/22/2025, the Order Summary indicated Resident 15 had an order for Tetrahydrozoline HCl ophthalmic solution with one drop instilled in both eyes twice a day for redness/itching, ordered on 8/20/2025.
During a concurrent observation and interview during a medication care inspection on 8/19/2025 at 3 pm with Licensed Vocational Nurse 7 (LVN 7), an open box of Care All redness reliever eye drops were labeled with “606A” on the top and side of the box with the bottle inside unlabeled with no date of opening. LVN 7 stated, the medication should be labeled by the nurse and eye drops were labeled with the open date and resident’s name on the bottle. LVN 7 stated they don't label the medication with a room number because the resident may change rooms, and they could give the medication to the wrong resident.
During an interview on 8/22/2025 at 11:54 am with the Director of Nursing (DON), the DON stated eye drops should be labeled upon opening with the date to allow nurses to know when to replenish it. The DON stated it must be labeled with the resident’s name and the room number on the bottle and the box but must be labeled on the bottle to prevent another resident from being given the medication.
During a review of the facility’s policy and procedure (P&P) titled, “Medication Labeling and Storage,” last revised 2/2023, the P&P indicated the labeling of medications and biologicals dispensed by the pharmacy were consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The P&P indicated, the medication label included, at a minimum the resident’s name.
c. During a medication Pass Observation on 8/21/2025 at 9:30 am with Licensed Vocational Nurse 8 (LVN 8) on Station 1, LVN 1 left the medication cart (MedCart) in the hallway unlocked and out of view where the residents and staff passed by.
During an interview on 8/21/2025 at 9:32 am, with LVN 8 on Station 1, LVN 8 stated “I did not lock my MedCart. I was nervous and I forgot to lock it. Someone might open the MedCart and might take medications that could cause harmful effect.”
During an interview on 5/16/2025 at 3:28 pm with the facility’s Director of Nursing (DON), the DON stated the MedCart needed to be locked if it was outside of the Licensed Nurse's view.
During an interview with the facility’s Director of Nursing (DON) on 8/21/2025 at 10:08 am, the facility DON stated, the MedCart should be locked every time if it was outside the view of licensed nurses for safety.
During a review of the facility’s undated Policy and Procedure titled, “Storage of Medications,” the P&P indicated, “Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended”
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 70 and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 70 and 244) received food that was palatable, attractive, and according to food preference according to the facility's Policy and Procedure (P&P) titled, Food and Nutrition Services, revised October 2017.These failures had the potential for Residents 70 and 244 to be at risk of unplanned weight loss, a consequence of poor food intake. Findings:
a. During a review of Resident 244's admission Record (AR), the AR indicated the facility admitted Resident 244 on 6/8/2022 and readmitted on [DATE] with diagnoses including respiratory failure (when the lungs can't get enough oxygen into the blood), dependence on respiratory ventilator (a type of breathing apparatus that moves air into and out of the lungs), and dependence on renal dialysis (the process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions naturally).
During a review of Resident 244's Minimum Data Set (MDS, a resident assessment tool) dated 5/27/2025, the MDS indicated Resident 244 had intact cognition (ability to understand). The MDS indicated Resident 244 was dependent (helper does all the effort) on staff for bathing, lower body dressing, and toileting and hygiene.
During a review of Resident 244’s History and Physical (H&P) dated 1/25/2025, the H&P indicated Resident 244 had the capacity to understand and make medical decisions.
During an interview on 8/21/2025 at 1:00 PM with Resident 244, Resident 244 stated the food served at the facility was “awful.” Resident 244 stated that the food the facility served did not look appetizing.
During a concurrent observation and interview on 8/21/2025 at 1:00 PM with Resident 244, Resident 244’s lunch tray included a plate of food containing a piece of meat. The surveyor and Resident 244 were not able to identify what kind of meat it was. The piece of meat looked unappetizing. Resident 244 stated Resident 244 did not want to eat lunch because the food did not look appetizing.
During a concurrent observation and interview on 8/21/2025 at 1:11 PM with Dietary Aid 1 (DA 1), DA 1 stated the piece of meat was baked chicken. DA 1 stated the chicken looked overcooked.
b. During a review of Resident 70’s AR, the AR indicated Resident 70 was admitted to the facility on [DATE] with diagnoses including unspecified severe protein-calorie malnutrition, dysphagia (difficulty swallowing) oropharyngeal (middle part of the throat located behind the mouth) phase, and muscle wasting and atrophy (partial or complete wasting away of a part of the body).
During a review of Resident 70’s Order Summary Report (OSR) dated 4/30/2025, the OSR indicated Regular Diet, Regular texture, Regular/Thin consistency, IDDSI (International Dysphagia Diet Standardization Initiative – an international collaboration of professionals who developed a standardized framework for labeling texture-modified foods and thickened liquids) Level 7 (foods are soft, tender, and easy to chew) for Resident 70.
During a review of Resident 70’s H&P dated 6/12/2025, the H&P indicated, Resident 70 had the capacity to understand and make decisions.
During a review of Resident 70’s MDS dated [DATE], the MDS indicated Resident 70 had intact cognition (ability to understand). The MDS indicated Resident 70 was independent (resident completes the activity by themselves with no assistance from a helper) for eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident).
During an interview on 8/20/2025 at 9:45 AM with Resident 70, Resident 70 stated, the facility did not have enough food variety. Resident 70 stated, Resident 70 requested no fish but Resident 70 was served fish. Resident 70 stated, Resident 70 would return the food served and food was of bad quality.
During a concurrent observation and interview on 8/21/2025 at 1:20 PM with Resident 70, Resident 70’s meal tray had chopped steamed spinach, grains, a lemon wedge and a light brown irregular shaped piece of meat with bubbled and crater-like texture and pinkish-red tinge colored section in the center part of the meat. Resident 70 stated, Resident 70 did not know what the piece of meat was on the meal tray. Resident 70 stated, the piece of meat did not look like a ground beef patty.
During a concurrent observation and interview on 8/21/2025 at 1:29 PM with Resident 70 and the Dietary Supervisor (DS), Resident 70’s meal tray had chopped steamed spinach, grains, a lemon wedge and a light brown irregular shaped piece of meat with bubbled and crater-like texture and pinkish-red tinge colored section in the center part of the meat. The DS stated the piece of meat was a ground beef patty. The DS stated, the DS would taste the ground beef patty on the ends and not the pink area. The DS stated the ground beef patty was pink when cooked. The DS stated, the ground beef patty did not “look like that when we get it.”
During a review of the facility’s Policy and Procedure (P&P) titled, “Resident Food Preferences,” revised 7/2017, the P&P indicated, the food service department would offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night.
During a review of the facility’s P&P titled, “Food and Nutrition Services,” revised 10/2017, the P&P indicated, each resident was provided with nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The P&P indicated, the food and nutrition services staff would inspect food trays to ensure that the correct meal was provided to each resident, the food appeared palatable and attractive. If an incorrect meal was provided to a resident, or a meal did not appear palatable, nursing staff would report it to the food service manager so that a new food tray could be issued.
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 each kitchen sanitization bucket (used to sanitize surfaces in the facility kitchen) and the sink sanitization compart...
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Based on observation, interview, and record review, the facility failed to ensure each kitchen sanitization bucket (used to sanitize surfaces in the facility kitchen) and the sink sanitization compartment used to sanitize tray line preparation area, was maintained at the required concentration for effective sanitization by failing to:Ensure two red buckets and the sink sanitization compartment (third compartment of the sink) used in the kitchen for sanitation of kitchen surfaces and in food preparation areas, were maintained at the correct concentration to maintain effectiveness to prevent cross contamination.Findings:During a concurrent observation and interview, on 8/19/25, at 9:56 a.m., with the Dietary Supervisor (DS), two of four red sanitization buckets and the sanitization compartment of the kitchen sink were tested for efficacy (ability to produce a desired or intended result). Two of the red bucket sanitizations and third sink compartment concentrations were observed at 50 parts per million (ppm). The DS stated the red buckets are filled from the third sink compartment. The DS stated red bucket concentration should be between 200-400ppm.During an interview, on 8/19/25, at 10 a.m., with the Registered Dietitian (RD), the RD stated it is important for the red bucket efficacy concentration to be maintained because of the safety and health issues of our patients, cross contamination, and we have sick people with compromised immune systems. During a concurrent interview, the DS stated it is important because patients can get sick.During an interview, on 8/21/25, at 9:35 a.m., with the DS, the DS stated the problem with the red sanitization buckets was that the test strips they were using to test had expired.During a record review of the manufacturer's guidelines, titled, Individual Sanitizer Testing Procedure, indicated the sanitization testing range should be 150-400ppm.
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 follow its infection control policy for five of seven...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its infection control policy for five of seven sampled residents (Residents 168, 175, 218, 1 and 105) by failing to ensure:a. The urine drainage bag was not touching the floor for Resident 168b. Resident 175 oxygen tubing was not touching the floor.c. Staff performed hand hygiene before and after taking care of Residents 218 and 1d. Resident 105's IV tubing was not looped at the end of the same administration set and the IV ports were not left uncovered.These deficient practices had the potential to result in infection for Residents 168, 175, 218, 1 and 105. a. During a review of Resident 168’s admission Record (AR), the AR indicated Resident 168 was admitted to the facility on [DATE] with diagnoses that included but not limited to fracture of neck, injury of head, quadriplegia (a form of paralysis that affects all four limbs, plus the torso), anxiety disorder (condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest).
During a record review of Resident 168’s History and Physical (H&P), dated 7/18/2025, the H&P indicated Resident 168 has the capacity to understand and make decisions.
During a review of Resident 168’s Minimum Date Set (MDS – a resident assessment tool), dated 7/23/2025, the MDS indicated Resident 168 required dependent care (helper does all of the effort, the resident does none of the effort to complete the activity) from staff for eating, oral, personal and toileting hygiene, shower/bathing self, upper and lower body dressing and putting on/taking off footwear.
During a review of Resident 168’s Order Summary (OS) dated 7/18/2025 at 4:24 PM, the OS indicated, “(Treatment) condom catheter: Monitor placement and patency (allow for free flow) every shift. Condom Catheter (a non-invasive urinary drainage device used primarily in males)- Medium size, May change PRN if leakage, blockage, dislodgement (removed) or soiled for Neurogenic bladder (a condition where the bladder muscles and nerves do not function properly due to damage) as needed.”
During an initial observation and interview of Resident 168 on 8/19/2025 at 10:53 AM, Resident 168 was observed to be resting in bed watching tv. Resident 168’s condom catheters drainage bag (a medical device, usually made of plastic, that collects urine) was hanging from the right side of the bed, not covered with privacy bag and touching the floor. The privacy bag was observed hanging next to the drainage bag.
During an interview with the Infection Preventionist Nurse (IPN) on 8/21/2025 at 3:02 PM, the IPN stated that a urine drainage bag should not be touching the floor because the floor has bacteria and that can cause an infection leading to more complications with the residents health.
During an interview with the Director of Nursing (DON) on 8/22/2025 at 9:07 AM, the DON stated the urine drainage bag should not be touching the floor. Per the DON, the facilities infection control policies indicate that if a urine drainage bag touches the floor, germs can enter the system, leading to a urinary tract infection (UTI-infection in the bladder). The bag should always be kept below the level of the bladder to prevent urine backflow and contamination, and the drainage spout or any part of the open system must not touch the floor or other surfaces.
During a review of the facilities Policies & Procedures (P&Ps) titled, “Policies and Practices-Infection Control”, revised October 2018, the P&P indicated “This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.”
b. During a review of Resident 175's admission Record (AR), the AR indicated the facility readmitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (paralysis on one side of the body), urinary tract infection (illness in urinary tract {system/organs that makes urine}), and hemorrhage of cerebrum (bleeding inside the brain).
During a review of Resident 175's Minimum Data Set (MDS, a resident assessment tool), dated 5/22/25, the MDS indicated Resident 175 was moderately cognitively (ability to understand and process thoughts) impaired, required substantial/maximal assistance with activities of daily living (ADLs), and mobility.
During a review of Resident 175’s History & Physical (H&P), dated 8/8/25, the H&P indicated Resident 175 did not have the capacity to make medical decisions.
During a review of Resident 175’s Physician Recapitulation Orders (PO), dated 8/21/25, the OSR indicated Resident 175 received 2-4 liters (L) of oxygen (O2) as needed (prn) for shortness of breath (SOB) and to keep the oxygen saturation (percentage of oxygen carried by red blood cells) above 92%.
During an observation, 8/20/25, at 9 a.m., Resident 175 was observed receiving 2L O2 via nasal cannula (flexible tube with two prongs that fit into the nostrils to deliver supplemental oxygen). Resident 175’s oxygen tubing was observed on the side of Resident 175’s bed and touching the floor.
During a concurrent observation and interview, on 8/20/25, at 9:11 a.m., with Licensed Vocational Nurse (LVN 13), Resident 175’s oxygen tubing was observed on the floor. LVN 13 stated Resident 175’s oxygen tubing touching the floor is an infection control issue and can cause an infection for sure.
During an interview, on 8/22/25, at 10:23 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated the oxygen tubing should definitely not be on the floor. The IPN stated this can cause germs on the tubing to the nose and it should be changed.
During a review of the facility’s Policy and Procedure (P&P), titled, “Infection Prevention and Control,” dated 2001, the policy indicated the facility's adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
c). During a review of Resident 1’s admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/2/2025 with diagnoses of toxic encephalopathy, acute respiratory failure with hypoxia, urinary tract infection, and resistance to vancomycin.
A review of Resident 1’s Care Plan Report (CP) dated 7/2/2025, the CP indicated staff were to perform proper hand hygiene prior to oral care to decrease Resident 1’s risk for developing Ventilator-Associated Pneumonia ([NAME]).
A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool) dated 7/8/2025, the MDS indicated Resident 1’s cognition (ability to understand) as rarely understood, there was a memory problem, skills for daily decision making were severely impaired, Resident 1’s arms and legs were severely impaired and that Resident 1 was totally dependent on staff for self-care.
A review of Resident 218’s admission Record (AR) dated 10/19/2024, the AR indicated Resident 218 has a diagnosis of Candidiasis (a yeast infection), unspecified (unable to determine the location).
A review of Resident 218’s Order Summary Report, dated 10/19/2024, the order summary report indicated Resident 218 has an active order, dated 2/19/2025, for enhanced barrier precautions, for five infectious (a germ) organisms.
During an observation on 8/20/2025 at 2:35 p.m., while at the door of Resident 218, LVN 9, did not perform hand hygiene before putting on gloves to assess Resident 218’s abdomen. LVN 9 did not perform hand hygiene after removing gloves, and LVN 9 did not perform hand hygiene before putting on another pair of gloves.
During an observation on 8/22/2025 at 8:59 a.m., while at the door of Resident 1’s room, RT 1, did not perform hand hygiene before putting on gloves to assess Resident 1’s ventilator (a machine to replace breathing of a person) machine, and did not cleanse hands after removing gloves and leaving Resident 1’s room.
During an interview on 8/20/2025 at 2:35 p.m., with LVN 9, LVN 9 stated staff should use soap or hand sanitizer before putting on gloves and after removing gloves.
During an Interview on 8/20/2025 at 3:18 p.m., with RN 1, RN 1 stated staff should perform hand hygiene with an alcohol based cleaner before touching residents. The process is to cleanse with an alcohol-based cleanser and put on a pair of clean gloves. After giving care, staff should remove gloves, dispose of them, then cleanse hands with the alcohol-based cleanser.
An interview on 8/22/2025 at 9:05 a.m., while outside Resident 1’s room, RT 1 stated if hand hygiene is not performed properly, germs can be spread from one resident to another.
A review of Handwashing/Hand Hygiene policy, dated revised April 2019, the Handwashing/Hand Hygiene policy indicated personnel should use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents.
d. During a review of Resident 105’s admission Record (AR), the AR indicated Resident 105 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), osteomyelitis (inflammation of bone or bone marrow, usually due to infection), and cellulitis (a skin infection that causes swelling and redness).
During a review of Resident 105’s Order Summary Report (OSR), dated 7/29/2025, the OSR indicated Resident 105 had an order for Zosyn (combination antibiotic used to treat a wide range of bacterial infections) Intravenous (IV, administered into a vein) Solution every six (6) hours for right heel osteomyelitis for 6 weeks.
During a review of Resident 105’s Minimum Data Set (MDS, a resident assessment tool), dated 8/2/2025, the MDS indicated Resident 105 had an intact cognition (ability to understand and process information). The MDS indicated Resident 105 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity) oral and toileting hygiene. The MDS indicated Resident 105 required substantial/maximal assistance (helper did more than half the effort) with shower, and lower body dressing.
During a concurrent observation while inside Resident 105’s room and interview on 8/19/2025 at 8:58 am with Certified Nurse Assistant 3 (CNA 3), Resident 105 was in bed on Resident 105’s back. Resident 105 had a right upper arm peripherally inserted central catheter (PICC, a thin flexible tube inserted into a vein in the upper arm and advanced into a larger vein in the chest near the heart) line with two (2) uncovered ports. CNA 3 stated Resident 105’s IV tubing was looped and tucked into another port of the same administration set.
During an interview on 8/21/2025 at 11:21 am with Registered Nurse Supervisor 1 (RN 1), RN 1 stated all PICC line ports and IV line tubing should be covered with IV [NAME] lock (a standard, threaded medical connector that provides a secure, twist-on, leak-proof connection for IV administration sets, syringes, and catheters) cap when not in use to prevent contamination and infection.
During an interview on 8/21/2025 at 11:38 am with the Assistant Director of Nursing (ADON), the ADON stated PICC line ports and IV-line tubing should not be left uncovered when not in use and loop at the end of the same administration set for infection control.
During a review of the facility’s policy and procedures (P&P) titled, “Administration Set/Tubing Changes,” revised February 2023, the P&P indicated, “Place a sterile end cap on the primary and/or secondary intermittent tubing when it is disconnected from the catheter. The sterile end cap is discarded when tubing is reconnected to the catheter. Do not attach (loop) the male [NAME] end of the administration set to a port of the same administration set.
During a review of the facility’s P&P titled, “Central Venous Catheter Care and Dressing Changes,” revised March 2022, the policy indicated its purpose is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings.”
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a clean and stain-free privacy curtain and wi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a clean and stain-free privacy curtain and window curtain for two of seven sampled residents (Resident 2 and Resident 3).This failure resulted in an unsanitary and non-homelike environment for the residents.a). During a review of Resident 2's admission Record (AR), the AR indicated the facility readmitted Resident 2 to the facility on [DATE] with diagnoses that included amyotrophic lateral sclerosis (nervous system disease), respiratory failure (lungs cannot properly exchange gases), and adult failure to thrive (syndrome characterized by weight loss, decreased appetite, poor nutrition). During a review of Resident 2's History & Physical (H&P), dated 2/23/25, the H&P indicated Resident 2 had the capacity to make medical decisions.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/4/25, the MDS indicated Resident 26 was cognitively intact (ability to understand and process thoughts), and was dependent in mobility and hygiene needs.b). During a review of Resident 3's admission Record (AR), the AR indicated the facility readmitted Resident 3 to the facility on 5/24/24 with diagnoses that included encephalopathy (neurologic disease), chronic obstructive pulmonary disease (lung diseases that block airflow), and epilepsy (disturbance in brain nerve cell activity).During a review of Resident 3's History & Physical (H&P), dated 5/25/25, the H&P indicated Resident 3 was awake and alert.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 7/4/25, the MDS indicated Resident 3 was moderately cognitively impaired (ability to understand and process thoughts), and mobility, hygiene, and transfers were independent.During a concurrent observation and interview, on 7/23/25, at 5:02 p.m., with Family (FAM 1), FAM 1 stated FAM 1 told staff about three months ago about Resident 2's soiled window curtain.During a subsequent concurrent observation and interview, with FAM 1, an ivory-colored curtain was observed with a large brown stain on the interior white side of the window curtain. FAM 1 stated the window curtain had the large brown stain since January 2025. FAM 1 stated Resident 2's room should be clean and neat. During a concurrent observation and interview, on 7/24/25, at 11:56 a.m., with Resident 3, Resident 3 stated Resident 3's curtains were dirty. Two or three grease-looking stains were observed on Resident 3's privacy curtain and a circular shaped black spot was observed on Resident 3's window curtain. Resident 3 stated they kept saying Resident 3 was on the list but housekeeping never did it and they have even told me they were going to fix them up but never did. Resident 3 stated Resident 3 has asked many times. Resident 3 stated Resident 3 had been in the facility for seven months and Resident 3's privacy curtain had never been cleaned. Resident 3 stated Resident 3 felt disappointed, and it does not feel like home.During a concurrent observation of Resident 3's privacy curtain, with the Housekeeping Supervisor (HS), on 7/24/25, at 2:20 p.m., Resident 3 stated Resident 3 has been in the room for seven months and privacy and the window curtains have not been changed and have spots on them. The HS stated there are spots on Resident 3's privacy curtain and the window curtain is just old.During a concurrent observation and interview, on 7/24/25, at 2:30 p.m., with the HS, Resident 2's window curtain was observed with a large brown stain on its interior. The HS stated No, Resident 2's window curtain is not clean. The HS stated this is not a homelike environment, this is their home, and it should be clean. The HS stated they must not have opened the curtains and checked the inside, only outside but, they should check inside. During a record review of the facility's Policy & Procedure (P&P), titled, Homelike Environment, revised on February 2021, the policy indicated residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment.
Jun 2025
5 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) received care and services to prevent maggot (immature, worm-like stage in t...
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Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) received care and services to prevent maggot (immature, worm-like stage in the life cycle of flies) infestation (when fly larvae (maggots) develop in a living organism's tissues or decaying organic matter) inside Resident 1's right ear, right nostril (openings in the nose) and mouth, by failing to:
a. Ensure Certified Nurse Assistant (CNA 4) obtained help from licensed nurses (Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs) and/or Respiratory Therapists (RTs) in the facility's Sub Acute Unit (SAU- specialized area for residents requiring more intensive skilled nursing care) to provide oral care (the practices and procedures aimed at maintaining and improving the health and well-being of the oral cavity, including the teeth, gums, tongue, and mouth) to Resident 1 in accordance with the facility's Policies and Procedure (P&P) titled Mouth Care, and Activities of Daily Living (ADL, basic self-care tasks that individuals perform to maintain their health and well-being) Supporting, to prevent the buildup of thick white material on Resident 1's tongue and dried reddish-brown dirt on Resident 1's teeth and the gums (tissue that surrounds the teeth).
b. Ensure facility's doors were closed and the screen doors (an exterior door with a mesh screen, typically made of wire or plastic, that allows air to pass through while blocking insects and other small debris from entering a building) were intact to prevent flies (insects) going inside the facility in accordance with the facility's P&P titled, Pest Control.
As a result, on 6/20/25, an in-house (within the facility) Dialysis (procedure to remove waste products from the blood) Technician (DT) 1, LVN 1 and RN 1 noticed five to eight maggots coming from Resident 1's right ear, right nostril, and mouth. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 6/20/25 at 4:20 pm and was diagnosed with septic shock (serious medical condition when an infection spreads throughout the body and causes very low blood pressure (force of blood).
On 6/26/25 at 4:02 pm, while onsite at the facility, 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) situation. The IJ was called in the presence of the Administrator (ADM), due to the facility's failure to ensure Resident 1 was free from maggot infestation. The ADM was aware that the deficient practice resulted in serious harm that threatened the health and safety of Resident 1.
On 6/27/25, the ADM provided an acceptable IJ Removal Plan (IJRP, a detailed plan that includes interventions to immediately correct the deficient practices in the IJ) for the facility's failure to ensure Resident 1 was free from maggot infestation in the facility. While onsite at the facility, the surveyor verified/confirmed implementation of the IJRP through observation, interview and record review, and determined the IJ situation of maggot infestation was no longer present. The surveyor removed the IJ on 6/27/25 at 8:08 pm in the presence of the ADM, Assistant Director of Nursing (ADON), Registered Dietitian (RD), Social Services Director (SSD), Dietary Services Supervisor (DSS), Quality Assurance (QA) Nurse, and Clinical Consultants.
The facility provided an acceptable IJRP as follows:
A. Immediate Corrective Actions:
1.On 6/20/25, Resident 1's nasal, ears and oral cavities were cleaned by facility medical team. A full body assessment was completed to check for additional infestations, none was identified. Resident 1 was transferred to GACH 1 for further evaluation.
2, On 6/20/25, the ADON verified all residents in the SAU received oral care, and scheduled shower and bed bath were provided. All residents in the SAU unit were assessed by the facility clinical team, complete body assessment done and no other resident was identified to be affected.
3. On 6/20/25, Resident 1's room underwent deep cleaning and was thoroughly disinfected by the housekeeping team.
B. Preventive and Corrective Actions:
1. From 6/24/25 - 6/25/25- Subacute Consultant provided in-service to all LVNs, RNs and RTs on Oral Care Procedure, Tracheostomy Site (a surgically created opening in the trachea [windpipe] that allows for the insertion of a tracheostomy tube) Care and Use and Handling of Toothbrush with Suction. The SAU Consultant conducted Clinical Skills Competency Checklist on nursing team and Respiratory Therapists.
2. On 6/26/25, the Exterminator company was called to service the conference room and surrounding areas of the facility.
3. On 6/27/25, the Administrator placed an order for four heavy duty rubber curtains to be installed at the patio doors to provide additional support and prevent insects from entering the facility. Three additional Fly Trap Lights were installed by Maintenance staff by the patio doors next to the social services office, smoking patio and hallway next to the kitchen. The Maintenance staff placed large fans by the patio doors to help blow air towards the patio and prevent insects flying inside the facility. The Maintenance Supervisor, Infection Preventionist (IP) and Clinical Consultants conducted a visual inspection of Resident 1's room, including furniture, under the bed, door frame and storage areas. The Clinical Consultant provided in-service to subacute clinical staff on the process to store supplies according to infection prevention practices. The Clinical Consultant provided in-service to housekeeping staff on ensuring all doors including patio, cabinets, bed frames, and furniture are kept clean and sanitized.
C. Systematic Change:
1. As of 6/27/25, all patients in the SAU have an updated order for oral care for ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured) and non-ventilator residents as ordered by the residents' health practitioners. The completion of oral care will be documented in the residents' clinical records.
2. As of 06/27/25, the Director of Staff Development (DSD) updated the annual in-service calendar to include oral care/hygiene every month for the first three months and quarterly thereafter.
3. The pest control vendor will increase frequency during the summer season to a minimum of twice a month and as needed.
4. The facility initiated the use of Chlorhexidine (a chemical compound used as an antiseptic and disinfectant) for oral care of residents in subacute unit for all residents with tracheostomy. Orders were obtained and carried out by the licensed nurses.
5. The facility initiated the use of the Suction Toothbrush System (a toothbrush with suction machine using electric suction, it clears saliva and food particles from the mouth, ensuring a comfortable experience), orders were placed, and the facility will start once the supply arrives.
6. The DON, ADON, IP, QA, and RN Supervisor will monitor resident hygiene at a minimum of twice a week by randomly selecting a minimum of three residents at different stations and visually inspecting and assessing to ensure oral care has been provided. Any negative findings will immediately be corrected, and additional training will be provided if deemed necessary. The findings will be reported to the Administrator and/or DON.
7. Nurse Managers would inspect the assigned rooms two to three times a week utilizing Adherence Compliance Review Tracking Log. The inspection included checking that the Fly Trap Lights were kept on, presence of flies in resident's rooms, windows/sliding doors are kept closed, and trash bins were kept clean. Any non-compliance will immediately be reported to the Administrator, IP Nurse and Maintenance for immediate corrective actions.
8. Additional Fly Trap lights would be installed by the Maintenance Department throughout the facility as soon as the order has arrived.
9. The Maintenance Department would install Heavy Duty Door Curtain at patio doors to prevent insects and flies entering the facility as soon as the order has arrived.
10. The IP Nurse will conduct random rounds for a minimum of three times a week in the SAU to check for flies, other insects, open doors and trash bins. Any negative findings will be immediately corrected and will be reported to the ADM and/or DON.
11. During the facility's monthly scheduled QAPI meetings, the results of the inspections and audits will be analyzed by the ADM and/or DON. Any findings or non-compliance identified with this deficient practice will be reported to the Quality Assurance and Performance Improvement (QAPI, a systematic, comprehensive, and data-driven approach to maintaining and improving the quality of care and services in healthcare settings) Committee monthly for review and further recommendations.
Cross Reference- F925
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility of 6/13/25 with diagnoses including metabolic encephalopathy ( brain dysfunction due to chemical imbalance in the body), respiratory failure ( a condition when the lungs cannot get enough oxygen into the blood), attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing) and end stage renal disease ( ESRD- is a medical condition in which a person's kidneys cease functioning on a permanent basis ) and dependent on renal dialysis (procedure to remove metabolic waste products or toxic substances from the bloodstream ).
During a review of Resident 1's Physician's Order (PO) dated 6/12/25, the PO indicated bedside dialysis on Monday, Wednesday and Friday, one time a day for ESRD.
During a review of Resident 1's Physician History and Physical (H&P) dated 6/14/25, the H&P indicated Resident 1 was on mechanical ventilation (a machine that supports breathing) secondary to pulmonary edema (fluid buildup in the lungs making it hard to breathe).
During a review of Resident 1's Interdisciplinary Team (IDT- a group of health care professionals who work together toward the goals of their patients) Conference Record dated 6/16/25 at 8:34 pm, the IDT conference record indicated Resident 1 required total assistance with bed mobility (ability to move and change positions in bed), toileting, dressing, and bathing.
During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 6/17/25, the MDS indicated Resident 1 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 1 was dependent (helper does all the effort and the resident does none of the effort to complete the activity) with staff for oral hygiene, toileting, bathing, and personal hygiene.
During a review of Resident 1's Situation Background Assessment Recommendation (SBAR- communication tool used in healthcare setting to help share important information among team members) form, dated 6/20/25, untimed, the SBAR indicated DT 1observed whitish moving objects coming from the resident's right nostril, mouth and right ear.
During a review of Resident 1's Progress Note (PN) dated 6/20/25, the PN indicated on 6/20/25 at 1:30 p.m. Treatment Nurse 1 (TN1) informed RN 1 of whitish moving bodies (maggots) from Resident 1's mouth. RN 1 assessed Resident 1's mouth and removed the whitish moving bodies from the mouth, right ear, and right nostril. The PN indicated Resident 1 was transferred to GACH 1 on 6/20/25 at 4:20 PM.
During a review of Resident 1's GACH 1 Intensive Care Discharge Summary (ICDS) dated 7/1/25, the ICDS indicated Resident 1 had hypotension (low blood pressure) and tachycardia (fast heart rate) upon arrival at the Emergency Department (ED). The ICDS indicated Resident 1 was given medications to increase Resident 1's blood pressure. The ICDS indicated Resident 1 was non-responsive to painful stimuli (to create a reaction) in the ED with multi-organ failure (a critical condition that occurs when two or more organs fail to function) a debilitated condition (a state of physical or mental weakness that decreases normal function). The ICDS indicated Resident 1 was placed on comfort care (medical care focused on relieving pain rather than curing/treating an illness). The ICDS indicated Resident 1 had discharge diagnoses including septic shock, severe sepsis (infection spreads throughout the body) and meal worm in naris (nostrils).
During an observation on 6/24/25 at 12:01pm, the facility's trash dumpster located outside of the facility, in front of the back double door, near the SAU was uncovered. The dumpster's lid was open and overflowing with trash.
During an interview on 6/24/25 12:05pm with Certified Nurse Assistant (CNA 3), CNA 3 stated CNA 3 have seen flies in some of the residents' rooms (unable to recall which rooms). CNA 3 stated all the screen doors needed to be closed and fly lights should be working. CNA 3 stated CNA 3 saw flies inside of the facility this morning (6/24/25).
During an observation inside of the conference room, on 6/24/25 at 1:45 pm, one live fly was flying up and down in the conference room.
During an interview on 6/24/25 at 2:15pm with the Maintenance Assistant (MA), the MA stated, it was important that nurses (in general) report right away when they see pests or flies due to some residents not being able to move and the flies and gnats could get on the residents.
During an observation in the conference room on 6/25/25 at 9:45 am, one live gnat was observed flying inside the conference room.
During an observation in the hallway on 6/25/25 at 11:33 am, one live fly was flying back and forth from the hallway.
During an interview on 6/26/25 at 9:10 am with the ADON, the ADON stated in the SAU where Resident 1 was housed, oral care was done by RTs, and licensed nurses. The ADON stated CNAs only clean the outside of the residents' (residents in the SAU) mouth. The ADON stated oral care to residents in the SAU must be done every shift and as needed. The ADON stated the oral care must be documented on the RT flow sheet and nurses' notes. The ADON stated suctioning was done by RTs or licensed nurses. The ADON stated it was important to check the windows and ensure the doors were closed to prevent flies and insects from going into the facility and into the residents' rooms, lay eggs and develop maggot infestation on the residents (residents in the SAU). The ADON stated, in the SAU, residents were immobile, unresponsive and unable to protect themselves nor remove the bugs/pests. The ADON stated, this time of the year with the hot weather, there would be a lot of bugs/pests that could go inside the facility. The ADON stated licensed nursing staff should ensure oral care was provided to the residents, especially those residents with tracheostomy and or on ventilator.
During an interview on 6/26/15 at 9:38 am with RN 1, RN 1 stated Resident 1 was transferred to GACH 1 on 6/20/25 and had not returned back to the facility. RN 1 stated, on 6/20/25 during Resident 1's dialysis session, DT 1, Resident 1's family member and TN 1 saw two little white moving objects (maggots) coming out of Resident 1's right nostril, one coming outside Resident 1's right ear, and five coming out of Resident 1's mouth. RN 1 stated it was important not to have flies in the facility because the residents in the SAU cannot move on their own and flies could lay eggs inside their mouth and tracheostomy. RN 1 stated she had not performed oral care to Resident 1 on the morning of 6/20/25 due to Resident 1's dialysis session.
During an interview with LVN 1 on 6/26/25 at 10:45 am, LVN 1 stated, Resident 1 slept with Resident 1's mouth wide open. LVN 1 stated Resident 1always kept Resident 1's mouth open. LVN 1 stated Resident 1 had a thick white layer on Resident 1's tongue that was not easily removed when LVN 1 provided oral care to Resident 1 on 6/20/25. LVN 1 stated there were flies in the SAU hallway and stated after Resident 1 was found with maggots on 6/20/25, flies could still be found in the facility. LVN1 stated on 6/20/25 at 4:30 pm, the dialysis RN supervisor came to inform LVN 1 that DT 1 noticed worms/maggots coming from Resident 1's nose. LVN 1 stated LVN 1 accompanied TN 1 to assess Resident 1 and found one worm hanging from Resident 1's right nostril. LVN 1 stated TN 1 went to get RN 1. LVN 1 stated RN 1 removed the worms and had to dig into Resident 1's mouth to remove all of them (5 maggots). LVN 1 stated there was also one worm on the right side of Resident 1's pillow and others in Resident 1's nose. LVN 1 stated, RN1 described the moving objects from Resident 1's mouth and nose as whitish moving objects, but the RN Dialysis Supervisor and DT 1 stated they were worms/maggots.
During an interview on 6/26/25 at 2:26 pm with CNA 4, CNA 4 stated CNA 4 took care of Resident 1 on the night shift (11pm-7am) of 6/19/25. CNA 4 stated CNA 4 performed oral care for Resident 1, but CNA 4 only cleaned around Resident 1's lips. CNA 4 stated CNA 4 did not clean the inside of Resident 1's mouth because Resident 1's mouth was closed. CNA 4 stated CNA 4 did not ask the assigned RT or licensed nurse for Resident 1 to assist CNA 4 with oral care due to Resident 1's mouth looked clean from the outside.
During an interview on 6/26/25 at 2:35 pm with DT 1, DT 1 stated, on 6/20/25 during Resident 1's dialysis session, while talking to Resident 1's sister, DT 1 noticed something was moving on Resident 1's beard, and something coming out of Resident 1's nostrils. DT 1 stated it was a maggot or something like a worm. DT 1 called Dialysis RN and Dialysis RN saw more than five worms coming out of Resident 1's nostrils. DT 1 stated Resident 1 kept Resident 1's mouth open all the time. DT 1 stated DT 1 did not check the inside of Resident 1's mouth and DT 1 assumed Resident 1's mouth was clean.
During a review of the facility's P&P titled, Mouth Care, revised 2/2018, the P&P indicated to keep the resident's lips and oral tissues moist, to cleansed and freshen the resident's mouth and to prevent oral infection. The P&P indicated for staff to thoroughly wipe the roof of a resident's mouth, inside the cheeks, the tongue, and teeth with an applicator. The P&P indicated to change the applicators frequently and to moisten the inside of the resident's mouth, tongue and lips using a prepared swab or water-soluble lubricant (lubricant that dissolves in water).
During a review of the facility P&P titled Activities of Daily Living (ADL) Supporting, revised 3/2018, the P&P indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLS. The P&P indicated residents who are unable to carry out ADL independently will receive the services necessary to maintain good grooming and personal and oral hygiene.
During a review of the facility's P&P titled Pest Control, revised 5/2018, the P&P indicated the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. The P&P indicated windows are screened at all times.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain informed consent (the voluntary agreement of a resident or a resident ' s representative to accept a treatment or procedure after re...
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Based on interview and record review, the facility failed to obtain informed consent (the voluntary agreement of a resident or a resident ' s representative to accept a treatment or procedure after receiving information regarding risks and benefits of the treatment) from one of one sampled resident (Resident 9) prior to administering the covid vaccine (a substance that helps the body ' s immune system learn to recognize and fight off the coronavirus [an infectious disease caused by the SARS-Cov-2 virus]) when Infection Prevention Nurse (IPN) 2 requested consent for the covid vaccine from Resident 9 ' s Family Member (FM) 1 instead of Resident 9.
This failure resulted in Resident 9 receiving the covid vaccine without giving consent.
Findings:
During a review of Resident 9 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/24/2025 with diagnoses including encephalopathy (a disturbance of brain function) and hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue damage) affecting the right dominant side (the preference of a person to use the right side of their body for everyday tasks).
During a review of Resident 9 ' s History and Physical (H&P), dated 4/24/25, the H&P indicated Resident 9 had the capacity to understand and make decisions.
During a review of Resident 9 ' s Pharmacist Order, dated 6/20/2025, the pharmacist order indicated Spikevax (a brand name for the covid vaccine) was ordered and given to Resident 9 on 6/20/2025.
During an interview on 6/25/2025 at 11:36 a.m. with IPN 2, IPN 2 stated IPN 2 called FM 1 to get consent for the covid vaccine for Resident 9. IPN 2 stated IPN 2 called FM 1 to get consent because Resident 9 is Spanish speaking and non-verbal.
During an interview on 6/25/2025 at 1:10 p.m. with Resident 9 and FM 1, Resident 9 stated Resident 9 did not give consent to receive the covid vaccine. FM 1 stated FM 1 never spoke to anyone from the facility to get a consent for Resident 9 to receive the covid vaccine. Resident 9 stated Resident 9 received a shot in Resident 9 ' s right arm on 6/20/2025. Resident 9 stated prior to receiving the shot, Resident 9 was told the shot would help Resident 9 ' s right arm to move better. Resident 9 stated Resident 9 was not told the shot was a covid vaccine.
During an interview on 6/26/2025 at 1:50 p.m. with the Assistant Director of Nursing (ADON), the ADON stated since Resident 9 had the capacity to make decisions IPN 2 should have gotten consent for the covid vaccine from Resident 9.
During a review of the facility ' s Policy and Procedure (P&P) titled, Coronavirus Disease (Covid-19)-Vaccination of Residents, dated 2001, with a revision date of June 2022, the P&P indicated, .The resident (or resident representative) has the opportunity to accept or refuse a COVID-19 vaccine, and to change his/her decision.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 2,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 2, 3, and 8) were treated with dignity and respect by CNA 1 who slapped Resident 2 on the hand, spoke rudely to Resident 2, refused to change the television channel for Resident 3, and did not provide perineal care (washing the genital and anal area) for Resident 8.
This failure resulted in Residents 2, 3, and 8 feeling upset and frustrated at not having their needs met and had the potential for Residents 2, 3, and 8 to experience feelings of decreased self-worth.
Findings:
a). During a review of Resident 2 ' s admission Record (AR), the AR indicated the facility admitted Resident 2 on 6/19/2023 with a readmission date of 3/1/2024 with diagnoses including respiratory failure (a medical condition that happens when your lungs cannot get enough oxygen), dependence on a ventilator (a machine used to support or replace the breathing of a person), and lack of coordination (the ability of the body to work together to perform movements or actions).
During a review of Resident 2 ' s Minimum Data Set (MDS- a resident assessment tool), dated 6/12/2025, the MDS indicated Resident1 ' s cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with eating, substantial/maximal assist (helper does more than half the effort) with oral hygiene, and was dependent (helper does all the effort) with toileting, shower/bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 2 was dependent with rolling left and right (the ability to roll from lying on back to left and right side and returning to lying on back on the bed), sit to lying, lying to sitting on side of bed, and tub/shower transfer.
b). During a review of Resident 3 ' s AR, the AR indicated the facility admitted Resident 3 on 6/25/2025 with diagnoses including respiratory failure and muscle wasting and atrophy (a decrease in muscle mass and tissue, often resulting in reduced strength and impaired mobility).
During a review of Resident 3 ' s History and Physical (H&P), dated 6/27/25, the H&P indicated Resident 2 had the capacity to make decisions.
c). During a review of Resident 8 ' s AR, the AR indicated the facility admitted Resident 8 on 10/2/2024 with diagnoses including respiratory failure, muscle wasting and atrophy, and paraplegia (a loss of the ability to move and sometimes feel anything in the legs and lower body).
During a review of Resident 8 ' s MDS, dated [DATE], the MDS indicated Resident 8 ' s cognitive skills for daily decision making were intact. The MDS indicated Resident 8 was dependent in oral hygiene, toileting, shower/bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 8 was dependent with roll left and right and tub/shower transfer.
During a review of Resident 8 ' s Grievance/Complaint Report Form, dated 6/9/2025, the grievance form indicated .CNA 1 has a bad attitude and only changed Resident 8 one time every shift .
During an interview on 6/27/2025 at 10:30 a.m. with Resident 8, Resident 8 stated when CNA 1 was taking care of Resident 8 on 6/8/2025 CNA 1 did not change Resident 8 ' s brief (a type of disposable absorbent garment used to manage incontinence [lack of voluntary control over urination or defecation] in adults) when requested and Resident 8 had to wait over an hour to have the brief changed. Resident 8 stated this made Resident 8 feel frustrated at not receiving proper care.
During an interview on 6/27/2025 at 10:40 a.m. with Resident 3, Resident 3 stated when Resident 3 requested CNA 1 to change the television channel on 6/26/2025, CNA 1 would not change the channel. Resident 3 stated Resident 3 felt upset because CNA 1 would not do what Resident 3 asked.
During an interview on 6/27/2025 at 10:55 a.m. with Resident 2, Resident 2 stated CNA 1 slapped Resident 2 ' s hand and said don ' t do that when Resident 2 was scratching Resident 2 ' s hand. Resident 2 told CNA 1 that Resident needed some anti-itch cream applied to Resident 2 ' s perineal area and CNA 1 told Resident 2 not to tell CNA 1 how to do CNA 1 ' s job. Resident 2 stated this made Resident 2 feel angry.
During an interview on 6/27/2025 at 11:35 a.m. with Resident 8 ' s Family Member (FM) 2, FM 2 stated Resident 8 had a soiled brief on 6/8/2025, FM 2 asked CNA 1 to help change Resident 8 ' s brief. CNA 1 told FM 2 CNA 1 was going to change another resident first and start showers for other residents before helping Resident 8. FM 2 stated Resident 8 had to wait for over an hour before a staff member came in and assisted with Resident 8 ' s brief change.
During an interview on 6/27/2025 at 10 a.m. and 12 p.m. with the Director of Staff Development (DSD), the DSD stated a resident (no name recall) complained of feeling uncomfortable when CNA 1 touched the resident ' s arm and told the resident not to scratch. The DSD stated it is the policy of the facility for staff members to treat the residents with dignity and respect. The DSD stated CNA 1 should not touch the residents in any way that would make the residents feel uncomfortable. The DSD stated residents ' requests should be provided, if possible.
During an interview on 6/27/2025 at 12:24 p.m. with the Assistant Director of Nursing (ADON), the ADON stated if requested, the CNA should change the television channel for the resident, and it is never acceptable for a CNA to slap a resident ' s hand. The ADON stated it is the right of the residents to be treated with kindness, dignity, and respect.
During a review of the facility ' s Policy and Procedure (P&P) titled, Resident Rights, dated 2001, with a revision date of December 2016, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' right to: a dignified existence, be treated with respect, kindness, and dignity, be free from abuse, self-determination .
During a review of the facility ' s P&P titled, Perineal Care, dated 2001, with a revision date of February 2018, the P&P indicated, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident ' s skin condition.
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 F0825
(Tag F0825)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide occupational (a treatment focused on improving the performance of activities required in daily life) and physical therapy (a treatm...
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Based on interview and record review, the facility failed to provide occupational (a treatment focused on improving the performance of activities required in daily life) and physical therapy (a treatment focused on improving or restoring physical movement and function) to one of one sampled residents (Resident 9) who was discharged from physical therapy after receiving four days of physical therapy and occupational therapy after receiving five days of occupational therapy.
This failure resulted in Resident 9 not receiving rehabilitative services and had the potential to result in further decline of physical, functional, and psychosocial well-being.
Findings:
During a review of Resident 9 ' s general acute care hospital (GACH) H&P record, dated 4/23/2025, the GACH record indicated, Will plan for transfer to rehab if remains clinically stable. Will do aggressive physical therapy/occupational therapy, discussed with Family Member (FM) 1 the need for long-term rehab given his weakness.
During a review of Resident 9 ' s GACH Occupational Therapy Inpatient Weekly Progress Note, dated 4/23/2025, the GACH progress note indicated, Assessment: Patient displays improved self-care abilities and functional balance/endurance as compared to last week. Resident 9 also displays increased right upper extremity strength. Patient will benefit from additional occupational therapy intervention based on above findings . Recommendations: Patient may benefit from skilled therapy with good potential to progress towards prior level of function.
During a review of Resident 9 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/24/2025 with diagnoses including encephalopathy (a disturbance of brain function) and hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue damage) affecting the right dominant side (the preference of a person to use the right side of their body for everyday tasks).
During a review of Resident 9 ' s History and Physical (H&P), dated 4/24/25, the H&P indicated Resident 9 had the capacity to understand and make decisions.
During a review of Resident 9 ' s Physical Therapy Initial Evaluation, dated 4/25/2025, the evaluation indicated Resident 9 had a rehab potential of fair with a frequency and duration of six times per week for four weeks. The evaluation indicated a discharge from physical therapy date of 4/29/2025.
During a review of Resident 9 ' s undated Physical Therapy Treatment Record, the treatment record indicated Resident 9 received physical therapy on 4/25/2025, 4/26/2025, 4/28/2025, and 4/28/2025.
During a review of Resident 9 ' s Occupational Therapy Initial Evaluation, dated 4/25/2025, the evaluation indicated a treatment diagnosis of lack of coordination (the ability of the body to work together to perform movements or actions) and a patient goal as get better. The evaluation indicated a rehab potential of good with a frequency and duration of six times a week for four weeks. The evaluation indicated a discharge from occupational therapy date on 4/29/2025.
During a review of Resident 9 ' s undated Occupational Therapy Treatment Record (no date), the treatment record indicated Resident 9 received occupational therapy 4/25/2025-4/29/2025.
During a review of Resident 9 ' s Minimum Data Set (MDS- a resident assessment tool), dated 4/30/2025, the MDS indicated Resident 9 ' s cognitive (the ability to think and process information) skills for daily decision making were severely impaired. The MDS indicated Resident 9 required supervision or touching assistance (helper provides verbal cues, and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, substantial/maximal assistance (helper does more than half the effort) with oral hygiene, upper/lower body dressing, and putting on/taking off footwear, and dependent (helper does all of the effort) with toileting, shower/bathing, and personal hygiene. The MDS indicated Resident 9 was dependent on rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed) sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and tub/shower transfer.
During an interview on 6/25/2025 at 1:10 p.m. with FM 1, FM 1 stated Resident 9 had not been receiving physical and occupational therapy since being admitted to the facility.
During an interview on 6/25/2025 at 12:30 p.m. with Registered Physical Therapist (RPT) 1, RPT 1 stated Resident 9 was admitted to the facility with an order to receive physical therapy six times a week. RPT 1 stated Resident 9 was discharged from physical therapy after receiving four days of physical therapy because Resident 9 was not making progress.
During an interview on 6/25/2025 at 12:45 p.m. with the Registered Occupational Therapist (ROT) 1, ROT 1 stated Resident 9 was evaluated on 4/25/2025 for occupational therapy and received five occupational therapy sessions before being discharged from occupational therapy on 4/29/2025. ROT 1 stated Resident 9 was discharged from occupational therapy because Resident 9 was not making progress.
During a concurrent interview and record review on 6/26/2025 at 10:10 a.m. with RPT 1, Resident 9 ' s undated Physical Therapy Treatment Record was reviewed. The treatment record indicated Resident 9 required maximum assistance x 2 (resident requires 2 helpers to assist with exercise) with supine (lying in bed) to stand on 4/25/2025. The treatment record indicated Resident 9 required maximum assistance with supine to stand on 4/29/2025. RPT 1 stated maximum assistance is an improvement from maximum assistancex2. RPT 1 stated Resident 9 would have benefited from receiving more than four days of physical therapy. RPT 1 stated it is important for residents to receive physical therapy to improve their physical functioning and independence.
During a concurrent interview and record review on 6/26/2025 at 10:30 a.m. with ROT 1, Resident 9 ' s undated Occupational Therapy Treatment Record was reviewed. The treatment record indicated Resident 9 required set up assistance (requires a helper to assist) with eating on 4/25/2025 and set up assistance/modified independent (the resident can do the exercise themselves) on 4/29/2025. ROT 1 stated a resident who goes from set up assistance to set up assistance/modified independent is showing signs of improvement. ROT 1 stated Resident 9 would have benefited from receiving more occupational therapy services.
During an interview on 6/26/2025 at 1:50 p.m. with the Assistant Director of Nursing (ADON), the ADON stated it was reasonable to have given Resident 9 more than four days of physical therapy and five days of occupational therapy.
During a review of the facility ' s undated Policy and Procedure (P&P) titled, Purpose of Physical Therapy Services, (the P&P indicated, Purpose of physical therapy service: to provide optimum quality of physical therapy patient care for in-and-outpatients .patients are accepted with the following diagnosis: .neurological disabilities, other disabilities which may be improved by services provided by physical therapy.
During a review of the facility ' s undated P&P titled, Therapy Referral Procedures, the P&P indicated, Accurate, thorough and timely documentation is essential in providing quality patient care. Thes enables therapists to communicate to the facility, the physician and other team members, the progress the patient is making along with justifying therapy that is being given Documentation by therapists is an important aspect along with quality treatment of his/her job performance.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure facility's doors were closed and facility's sc...
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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 facility's doors were closed and facility's screen doors and windows (an exterior door/window with a mesh screen, typically made of wire or plastic, that allows air to pass through while blocking insects and other small debris from entering a building) were intact to prevent flies and other insects from going inside the facility, in accordance with the facility's policy and procedure (P&P) titled, Pest Control.
This failure resulted in flies and other insects entering the facility and had the potential for flies and other insects to spread diseases to all 220 residents in the facility.
Findings:
During an interview on 6/24/25 at 11:41 am with Licensed Vocational Nurse (LVN) 3, LVN 3 stated LVN 3 sees gnats (insects) in residents' rooms especially in the rooms with juices, drinks, and foods. LVN 3 stated staff (in general) would inform the Maintenance Department (MD), whenever staff (in general) saw insects inside the facility.
During an observation on 6/24/25 at 12:01 pm, the facility's trash dumpster located outside of the facility, in front of the back double door, near the Subacute Unit (SAU - specialized area for residents requiring more intensive skilled nursing care) was uncovered. The dumpster's lid was open and overflowing with trash.
During an interview on 6/24/25 at 12:05 pm with Certified Nursing Assistant (CNA) 3, CNA 3 stated CNA 3 saw flies in room [ROOM NUMBER] and room [ROOM NUMBER] today (6/24/25). CNA 3 stated all staff were supposed to make sure that all the window and door screens were closed and fly lights were working. CNA 3 stated CNAs were also supposed to report to the licensed nurses as soon as possible whenever CNAs see flies or other insects. CNA 3 stated CNA 3 saw MD staff inside room [ROOM NUMBER] and room [ROOM NUMBER] this morning (6/24/25) to take care of the flies.
During an interview on 6/24/25 at 12:19 pm with Resident 4, Resident 4 stated Resident 4 saw gnats around the sandwiches in Resident 4's room (room [ROOM NUMBER]) this morning (6/24/25).
During an interview on 6/24/25 at 12:23 pm with Resident 5, Resident 5 stated Resident 5 saw either a fly or a gnat flying around in Resident 5's room (room [ROOM NUMBER]) a minute ago.
During an interview on 6/24/25 at 12:45 pm with Resident 6, Resident 6 stated Resident 6 had seen flies and gnats in Resident 6's room (room [ROOM NUMBER]) the day before yesterday (6/22/25).
During an interview on 6/24/25 at 1:03 pm with Resident 7, Resident 7 stated Resident 7 had seen flies in Resident 7's room (room [ROOM NUMBER]). Resident 7 stated Resident 7 and Resident 7's visitors were trying to kill the flies inside Resident 7's room with a newspaper the day before yesterday (6/22/25).
During an observation inside of the conference room, on 6/24/25 at 1:45 pm, one live fly was flying up and down in the conference room.
During an interview on 6/24/25 at 2:15pm with the Maintenance Assistant (MA), the MA stated, it was important that nurses (in general) report right away when they see pests or flies due to some residents not being able to move and the flies and gnats could get on the residents.
During an observation in the conference room on 6/25/25 at 9:45 am, one live gnat was observed flying inside the conference room.
During an interview on 6/26/25 at 9:10 am with the Assistant Director of Nursing (ADON), the ADON stated it was important to check the windows and ensure the doors were closed to prevent flies and insects from going into the facility and into the residents' rooms, lay eggs, and develop maggot infestation on the residents especially on residents with tracheostomy (a surgically created opening in the trachea [windpipe] that allows for the insertion of a tracheostomy tube [artificial airway for breathing]) and or on the ventilator (a medical device to help support or replace breathing) in the SAU. The ADON stated, in the SAU, residents were immobile, unresponsive and unable to protect themselves nor remove the bugs/pests. The ADON stated, this time of the year with the hot weather, there would be a lot of bugs/pests that could go inside the facility.
During an interview on 6/26/15 at 9:38 am with Registered Nurse (RN)1, RN 1 stated it was important not to have flies in the facility because the residents in the SAU cannot move on their own and flies could lay eggs inside their mouth and tracheostomy.
During an interview on 6/26/25 at 10:45 am with LVN 1, LVN 1 stated there were flies in the SAU hallway and in the facility.
During a review of the facility's P&P titled Pest Control, revised 5/2018, the P&P indicated the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. The P&P indicated windows are screened at all times.
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
Pressure Ulcer Prevention
(Tag F0686)
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 7) was provided with the necessary treatment and services to prevent formatio...
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Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 7) was provided with the necessary treatment and services to prevent formation of and promote healing of an existing pressure injury (PI, injury to skin and underlying tissue resulting from prolonged pressure on the skin) by:
1. failing to ensure Resident 7 received physician-ordered wound care treatment for a stage 3 PI on Resident 7's right knee.
2. failing to follow the physician's order that indicated cleansing with normal saline (NS-sterile salt solution) and application of zinc oxide (barrier ointment) for Resident 7's sacrococcyx (sacral [a triangular shaped bone at the bottom of the spine] coccyx [tailbone]) stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) PI.
This failure resulted in an increased risk for an infection, pain, and further skin breakdown to Resident 7. Additionally, the failure had the potential to result in delayed wound healing to Resident 7.
Findings:
During a review of Resident 7's admission Record (AR), the AR indicated the facility originally admitted Resident 7 on 3/3/2022 and readmitted the resident on 5/24/2025 with diagnoses including epilepsy (a brain disorder that can cause people to suddenly become unconscious and have violent, uncontrolled movements of the body) and metabolic encephalopathy (a broad term for any brain disease that alters brain function).
During a review of Resident 7's History and Physical (H&P), dated 5/26/2025, the H&P indicated, Resident 7 did not have the capacity to understand and make decisions.
During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 6/3/2025, the MDS indicated Resident 7's cognitive (the ability to think and process information) skills for daily decisions making was severely impaired. The MDS indicated Resident 7 needed supervision to extensive assistance from the staff for activity of daily living (ADL, term used in healthcare that refers to self-care activities).
During a review of Resident 7's care plan (CP), dated 5/6/2025, the CP indicated Resident 7 had a stage 3 [PI] (full thickness tissue loss) on [Resident 7's] right knee. The CP's interventions included were to do treatment as ordered.
During a review of Resident 7's CP dated 5/6/2025, the CP indicated Resident 7 had a sacrococcyx stage 4 PI. The CP's interventions included to do treatment as ordered: collagen on the wound bed, zinc oxide on the periwound (the tissue surrounding the wound), and to cover [the wound] with dry dressing.
During a review of Resident 7's Order Summary Report (OSR), dated active as of 6/13/2025, the OSR indicated the following physician orders:
1. Right Knee Pressure injury; Cleanse with NSS (normal Saline Solution), pat dry, apply collagen powder, and cover with dry dressing daily x (for) 21 days then re-evaluate. Every day shift for Stage 3 [PI] for 21 days, dated 5/26/2025.
2. Sacrococcyx pressure injury-cleanse with NSS, pat dry, apply Medihoney (medical grade honey intended for wound care) to wound bed follow with calcium alginate (primary wound dressing derived from seaweed and are highly absorbent) and zinc oxide to the periwound and cover with dry dressing daily x 21days then re-evaluate. Every day shift for stage 4 [PI], dated 5/31/2025.
During a wound care observation on 6/12/2025 at 9:10 AM in Resident 7's room with Treatment Nurse1 (TN1). TN 1 cleansed Resident 7's sacrococcyx area wound with Hibiclens (wound cleanser, antiseptic), applied collagen, and covered the wound with a dressing.
During an interview on 6/12/2025 at 9:10AM with TN1, TN1 stated TN 1 used Hibiclens instead of normal saline, TN1 stated TN 1 did not apply zinc oxide to the sacrococcyx [stage 4] PI. TN1 stated TN 1 did not provide wound care to the Stage 3 PI on Resident 7's right knee.
During an interview on 6/12/2025 at 4:30PM with the Assistant Director of Nursing (ADON), the ADON stated it was essential for nurses to follow physician orders as they were based on the resident's clinical needs and represented basic nursing care standards. The ADON stated the use other products without a physician's order was not acceptable.
During a review of the facility's policy and procedure (P&P) titled, Wound Care, revised 10/2010, the P&P indicated the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. The P&P indicated to verify there was a physician's order for the procedure.
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 F0573
(Tag F0573)
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 three (3) of three sampled residents (Residents 4, 5, and 6...
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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 three (3) of three sampled residents (Residents 4, 5, and 6) or the Residents' Representative a copy of the residents' medical records upon request and within two working days from notice per the facility's policy and procedure titled, Release of Information.
This failure resulted violated Residents 4, 5, 6's rights and resulted in Resident 5 and Resident 4's and Resident 6's Representatives not receiving the medical records in timely manner.
Findings:
1. During a review of Resident 5's admission Record (AR), the facility admitted Resident 5 on 2/7/2025 with diagnoses that included unspecified injury at C5 level of the cervical spinal cord (spinal cord injury), fracture of the body of sternum (breastbone), and Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 5's History and Physical (H&P), dated 2/10/2025, the H&P indicated Resident 5 did have the capacity to understand and make decisions. The H&P indicated Resident 5 was alert, oriented, and competent to make complex medical decisions.
During a review of Resident 5's Minimum Data Set (MDS, a resident assessment), dated 2/13/2025, Resident 5 was cognitively (ability to understand and process information) intact. The MDS indicated Resident 5 required moderate (helper does less than half the effort) to substantial (helper does more than half the effort) assistance when performing activities of daily living (ADLs, a term used in healthcare that refers to self-care activities) such as toileting, oral, and personal hygiene. The MDS indicated Resident 5 required moderate to substantial assistance when transferring from chair to bed or bed to chair.
During a review of the AR, the facility discharged Resident 5 on 4/13/2025.
During a review of the facility's copy of Resident 5's Authorization for Release of Resident Information document, dated 4/22/2025, the document indicated the request for Resident 5's medical records was addressed to the facility.
During a concurrent record review and interview on 6/12/2025 at 2:35 PM with the Medical Records Assistant (MRA), the facility's Disclosure Log (the log the Medical Records Offices used to track medical records requests) was reviewed. The MRA stated, Resident 5 requested Resident 5's medical records on 4/29/2025, but the Medical Records Office did not receive the request until 5/2/2025. The MRA stated, Resident 5's medical records were released to Resident 5 on 5/22/2025 and again on 6/2/2025.
2. During a review of Resident 6's AR, the facility admitted Resident 6 on 10/14/2025 with diagnoses that included respiratory failure (difficulty for the resident to breathe on their own), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and End Stage Renal Disease (ESRD, irreversible kidney failure).
During a review of Resident 6's H&P, dated 10/24/2024, the H&P indicated Resident 6 did have the capacity to understand and made decisions.
During a review of Resident 6's MDS, dated [DATE], Resident 6 was cognitively intact. The MDS indicated Resident 6 was dependent (helper does all the effort) for bathing and toileting hygiene and needed substantial assistance for personal hygiene and ADLs. The MDS indicated Resident 6 needed substantial assistance with turning left to right in bed and transferring from the bed to chair or the chair to bed.
During a review of Resident 6's AR, the facility discharged Resident 6 on 2/10/2025.
During a review of the facility's copy of Resident 6's Authorization for Release of Resident Information document, dated 4/16/2025, the document indicated the request for Resident 5's medical records was addressed to the facility.
During a concurrent record review and interview on 6/12/2025 at 2:30 PM with the MRA, the facility's Disclosure Log was reviewed. The MRA stated, Resident 6's Representative request Resident 6's medical records on 5/7/2025, but the Medical Records Office did not receive the request until 5/16/2025. The MRA stated, Resident 6's medical records were released to Resident 6's Representative on 5/21/2025.
3. During a review of Resident 4's AR, the facility admitted Resident 4 on 1/10/2025 with diagnoses that included lumbar region spinal stenosis (narrowing of the spinal cannel which added pressure on the spinal cord and nerves) and hypertension (HTN, high blood pressure).
During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills were intact. The MDS indicated Resident 4 required substantial assistance performing when performing ADLs. The MDS indicated Resident 4 required substantial assistance turning from left to right in bed and transferring from the bed to chair or the chair to the bed.
During a review of Resident 4's AR, the facility discharged Resident 4 on 3/21/2025.
During a review of the facility's copy of Resident 4's Representative's Authorization for Release of Resident information document, dated 5/5/2025, the document indicated the request for Resident 4's copy of medical records was addressed to the facility.
During a review of Resident 4's Representative Notes, dated 5/8/2025, Resident 4's Authorization for Release of Patient information document was mailed to the facility.
During a review of Resident 4's Representative Notes, dated 5/12/2025, 5/19/2025, and 5/27/2025, Resident 4's Representative was unable to contact the facility regarding the status of Resident 4's medical records.
During a review of Resident 4's Representative Notes, dated 6/5/2025, Resident 4's Representative sent a follow up electronic mail (e-mail) to the facility requesting for Resident 4's medical records that has been past due for a while, and we [Resident 4's Representative] need the records as soon as possible.
During a concurrent record review and interview on 6/12/2025 at 2:40PM with the MRA, the facility's Disclosure Log was reviewed. The Disclosure Log indicated Resident 4's Representative requested Resident 4's medical records on 5/7/2025 and the request was reviewed on 5/19/2025. The MRA stated, Resident 4's medical records request was on 5/7/2025 but the MRA received Resident 4's medical records request from the Business Office
Manager (BOM) on 5/19/2025. The MRA stated, the MRA accidentally documented Resident 4's medical records review date wrong. The MRA stated, the date of review should have been 5/19/2025 when the Medical Records Office received the request from the BOM.
During a concurrent record review and interview on 6/12/2025 at 3:00PM with the MRA, the e-mail between the MRA and facility, dated 5/19/2025 was reviewed. The MRA stated, the MRA emailed the facility Resident 4's AR and Authorization for Release of Resident Information document. The MRA stated, after Resident 4's AR and Authorization for Release of Resident Information document were reviewed by the facility, the facility will email the MRA a link to upload Resident 4's medical records for the facility to review.
During a concurrent record review and interview on 6/12/2025 at 3:05PM with the MRA, the e-mail thread between the MRA and facility, dated 5/22/2025 timed at 1:25PM, was review. The MRA stated, the original link from the facility was not working and requested for another link to upload Resident 4's medical records.
During a concurrent record review and interview on 6/12/2025 at 3:08PM with the MRA, the email thread between the MRA and facility, dated 5/23/2025 timed at 9:08AM, was reviewed. The MRA stated, the facility was supposed to send a new link to upload Resident 4's medical records for review.
During a concurrent record review and interview on 6/12/2025 at 3:10PM with the MRA, the email thread between the MRA and facility, dated 6/2/2025 timed at 3:26PM, was reviewed. The MRA stated, the MRA sent a follow-up email to the facility related to the new link mentioned in the 5/23/2025 email.
During a concurrent record review and interview on 6/12/2025 at 3:12PM with the MRA, the email thread between the MRA and facility, dated 6/2/2025 timed at 3:52PM, was reviewed. The MRA stated, the MRA sent another follow-up email to the facility and will send the records after approval to release. The MRA stated, the MRA still has not received authorization from the facility to release Resident 4's medical records.
During an interview on 6/12/2025 at 3:35PM with the MRA, the MRA stated, the process of the release of medical records usually takes about one (1) week or five (5) business days, from when the Medical Records Office received the request to release of the medical records to the resident or resident representative.
During an interview on 6/12/2025 at 4:30PM with the Medical Records Director (MRD), the MRD stated documents should be released with five (5) working days. The MRD stated, it was important to release the resident's medical records within a timely manner because residents and the requester have the right to review their medical records.
During an interview on 6/13/2025 at 10:15AM with the BOM, the BOM stated the medical records request were either physically mailed or electronically faxed to the facility. The BOM stated, the BOM and the BOM's assistants were not actively looking for medical records request that were mailed or electronically faxed to the facility. The BOM stated, the BOM and BOM's assistants often encounter these medically records request while filtering through mail or received fax reports. The BOM stated, the medical records request should be given to the Medical Records Office as soon as possible.
During a review of the facility's policies and procedures (P&P) titled, Release of Information, dated 11/2009, the P&P indicated, a resident may obtain photocopies of his or her record by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying services.
May 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) had ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) had a clutter-free room environment and did not have multiple plugs in the electrical outlet.
These deficient practices placed Resident 2 at risk for accident hazards from a possible overloaded electrical circuit and heightened risk of fire with a cluttered area of flammable materials (ability to ignite easily and burn rapidly) surrounding Resident 2's bed.
Findings:
During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), acute kidney failure (kidneys suddenly lose their ability to filter waste and balance fluids and electrolytes), anxiety disorder (excessive and persistent fear or worry), depression (persistent sadness, loss of interest, and difficulty functioning) , and nicotine dependence (substance dependence on nicotine).
During a review of Resident 2's History and Physical (H&P) dated 5/20/24, the H&P indicated Resident 2 had the capacity to make decisions.
During a review of Resident's 2's Minimum Data Set (MDS, a resident tool) dated 2/19/25, the MDS indicated Resident 2 was independent with eating, upper/lower body dressing, personal hygiene, oral hygiene, toileting hygiene, shower/bathe self, and putting on/taking off footwear.
During an observation on 5/22/25, at 2:30 p.m., Resident 2 was observed alert and oriented sitting in a wheelchair next to Resident 2's bed. Resident 2's room environment was observed to be crowded with multiple personal items surrounding Resident 2's bed. There were eight (8) plugs observed connected to the two electrical outlets at the head of the bed.
During an interview on 5/22/25 at 3:49 p.m. with Registered Nurse (RN) 1, RN 1 stated RN 1 was aware of all the personal items crowding around Resident 2's bed in Resident 2's room. RN 1 stated the Social Services Director (SSD) and Administrator were informed, and the responsibility of addressing the resident's many items was handed off to the SSD and Administrator.
During an interview on 5/22/25 at 4:03 p.m. with the SSD, the SSD stated the SSD was aware that Resident 2 had many items in Resident 2's room, but none were blocking the paths to go in and out of Resident 2's room nor did any nursing staff inform the SSD about any issues giving Resident 2's care. The SSD stated the SSD was unaware that Resident 2 had multiple plugs connected to the two outlets at the head of Resident 2's bed. The SSD stated the SSD would let the Maintenance Department know about the multiple plugs because it was a fire hazard and safety issue. The SSD further stated, All staff have the responsibility to keep residents in the facility safe and their environments clutter free.
During a review of the facility's P&P titled, Maintenance Service, revised 12/2009, the P&P indicated, The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. The P&P further indicated, Functions of maintenance personnel include, but are not limited to . maintaining the building in good repair and free from hazards.
During a review of the facility's policy and procedures (P&P) titled, Homelike Environment, revised 2/2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The P&P further indicated, The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include . a clean, sanitary and orderly environment.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain a safe and functional shower for one (1) out of four (4) shower rooms in the facility with two holes in the wall loc...
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Based on observation, interview, and record review, the facility failed to maintain a safe and functional shower for one (1) out of four (4) shower rooms in the facility with two holes in the wall located where the wall meets the base of the tile floor.
This deficient practice had the potential for residents to be placed at risk for injury.
Findings:
During an observation on 5/22/25 at 1:40 p.m., two (2) holes in the shower wall at the base of the tile where it meets the wall were observed.
During a concurrent interview and record review on 5/22/25, at 1:46 p.m. with the Maintenance Worker (MW), the maintenance logs dated 1/2024 to 5/2025 were reviewed. The MW stated there was no documentation that staff requested shower or wall repairs in the maintenance logs. The MW stated the MW would have the wall repaired right away because it was a safety hazard to the residents who showered in that room.
During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, revised 12/2009, the P&P indicated, The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. The P&P further indicated, Functions of maintenance personnel include, but are not limited to maintaining the building in good repair and free from hazards.
May 2025
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Notification of Changes
(Tag F0580)
Someone could have died · This affected 1 resident
Based on interview and record review, the facility failed to promptly (quickly/timely) notify the physician for, one of 16 sampled residents (Resident 1), who experienced a change of condition (COC, a...
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Based on interview and record review, the facility failed to promptly (quickly/timely) notify the physician for, one of 16 sampled residents (Resident 1), who experienced a change of condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions) in accordance with the facilities policies and procedures (P&P) titled, Change in a Resident's Condition or Status, Resident Assessment and Examination, and Resident 1's Care Plan (CP) titled, Constipation ( difficulty in emptying the bowels), by failing to:
1. Ensure Registered Nurse (RN) 2 and RN 3 notified Resident 1's primary care physician/Medical Doctor (MD) 1 of Resident 1's COC, on 5/6/2025 at 8 am, when Resident 1 experienced abdominal distension (bloating and swelling in the belly area), abdominal firmness (abdomen feeling hard or tight to the touch), and complained of (unspecified/unrated) abdominal pain.
2. Ensure RN 4 notified MD 1 on 5/6/2025 when Resident 1's constipation (a problem with passing stool, hard stools, generally means passing fewer than three stools a week or having a difficulty passing stools), abdominal distension, and abdominal firmness did not improve after Resident 1 received magnesium citrate (medication used to treat occasional constipation and usually results in a bowel movement [BM, an act of defecation (expelling feces )/movement of feces] within 30 minutes from the time of medication administration) on 5/6/2025 at 4:38 pm.
3. Ensure RN 4,and Licensed Vocational Nurse (LVN) 4 notified MD 1 on 5/6/2025 at 11:10 pm when Resident 1 was noted to have shortness of breath (SOB, sensation of not being able to breathe enough air, or the feeling of suffocating or struggling to breathe), required supplemental oxygen (O2, colorless odorless gas, medical treatment that provides additional oxygen to individuals with breathing difficulties or have low blood oxygen levels), had abdominal distension with hypoactive bowel sounds (decreased/reduced sound made by the movement of the intestines/bowel [long tubed shaped organ in the abdomen that completes the process of digestion (the breakdown of food)] as the intestines push food through, indicating?slowed intestinal activity), and had a hard abdomen.
4. Ensure RN 4, and LVN 4 notified MD 1 on 5/7/2025 at 12:15 am, when Resident 1 complained of acute (fast/sudden) onset (beginning of something unpleasant) of 8 out of 10 pain (pain scale 0 to 10, 0 means no pain and 10 means the worst possible pain felt, 7 to 9 indicates severe pain) to Resident 1's abdomen.
As a result of these failures, on 5/7/2025 at 1:09 am, LVN 4 found Resident 1 unresponsive (a state in which an individual is unconscious and does not respond to stimuli such as voice, touch, or pain) in Resident 1's bed. Resident 1 had coffee ground emesis (act of vomiting, appears dark brown, coffee-ground-like substance). Resident 1 was not breathing and did not have a pulse (heartbeat). LVN 4 asked Certified Nursing Assistant (CNA) 5 to called 9-1-1 (phone number used to contact Emergency Medical Services [EMS, a system that responds to emergencies in need of highly skilled prehospital clinicians, also known as ambulance services] in the event of a medical emergency) and began cardio-pulmonary resuscitation (CPR - emergency lifesaving procedure performed when the heart stops or breathing is inadequate). Resident 1 was pronounced dead by Emergency Medical Technician (EMT, a person who is specially trained and certified to administer basic emergency services to victims of trauma or acute illness) at the facility on 5/7/2025 at 1:42 am.
On 5/8/2025 at 5:57 pm, while at the facility, the State Survey Agency (SSA) identified 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). The IJ was called in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to notify MD 1 when Resident 1 had a COC.
On 5/9/2025, while onsite at the facility, the facility provided an acceptable IJ Removal Plan (IJRP, a detailed plan that includes interventions to immediately correct the deficient practices of the IJ) for the facility's failure to notify MD 1 of Resident 1's COC. While onsite, the SSA verified and confirmed the facility's full implementation of the IJRP through observations, interviews, and record reviews, and determined the IJ situation, under Federal Code of Regulation (CFR) 483.10: Resident Right - Notify of Changes, was no longer present. The SSA removed the IJ on 5/9/2025 at 5:29 pm in the presence of the ADM and the DON.
The acceptable IJRP included the following immediate corrective actions:
1. On 5/08/2025, an in-service (training session) was initiated by the DON and the Assistant DON (ADON) to all licensed nursing staff (all RNs and LVNs). The facility employed a total of 84 LVNs and 20 RNs. On 05/08/2025 and on 05/09/2025 a total of 45 of 84 LVNs and 11of 20 RNs were in-serviced (trained) on COCs. The DON and the ADON will continue the in-services until all licensed and registered nurses are trained. Any Licensed Nurses (LNs) that are currently on medical leave or vacation will receive the training before they provide patient care.
The in-service included:
a. Contacting the physician as soon as possible for any resident's COCs specifically for residents with constipation, abdominal pain, abdominal distention, and abdominal firmness.
b. Contacting the resident's physician as soon as possible when there is a delay in medication and when a resident's symptoms do not improve or worsen during a COC.
c. Ensure accurate, complete, and timely documentation.
d. Complete an accurate assessment of the residents' overall condition and thorough documentation.
2. On 05/08/2025, the DON provided an in-service to direct care staff including nursing assistants in recognizing subtle but significant changes in the resident condition and how to communicate these changes to the LNs. The facility employed 119CNAs and Restorative Nursing Aides (RNAs, nursing aide program that helps residents maintain their function and joint mobility) combined. On 05/08/2025 and 05/09/2025 a total of 32 CNAs/RNAs were in-serviced. The DON and the Director of Staff Development (DSD) will continue training until all CNAs and RNAs are re-educated. Any CNA/RNA that was on medical leave or vacation will be trained before they provide patient care. CNAs were re-educated and encouraged to use the Stop and Watch Early Warning Tool (form used when a resident is not his/her usual self to help staff recognize and respond when the resident is becoming unwell) to communicate subtle changes in the residents' condition.
3. On 05/08/2025 and 05/09/2025, the medical records team conducted an audit of change in a resident's condition or status with emphasis on timely physician notification. A total of 172 residents are currently on bowel regimen (a schedule of medicines that help keep a person's BMs regular) to prevent constipation. The audit results showed 3 residents were identified as not having a BM for three days.
4. On 05/09/2025, the facility identified Resident 4, Resident 5, and Resident 6 who had no BM for three days, the residents were assessed by assigned LNs and the steps stated below were followed.
The audit results are reviewed by the RN Supervisor to ensure:
a. Any changes to the residents' condition are communicated to the primary physician for any recommendations and for new orders.
b. The nursing team has documented in the residents' medical record relative to changes in the residents' medical/mental condition or status.
c. The residents' CP is updated to reflect the residents' COCs.
d. The licensed nursing staff documents in the residents' clinical record for the COC reported or assessed by licensed nursing staff.
e. The RN Supervisor has validated the completion of the SBAR (structured communication framework that helps teams share information about the condition of a resident) by LNs.
5.On 05/09/2025, the DON and Regional Clinical Consultant initiated Competency Skill Checks for all RNs on COCs, notification of physicians, changes/worsening conditions, specific system assessment with emphasis on bowel management (bowel regimen, a schedule of medicines that helps a person have BMs), Point Click Care, (PCP, a healthcare software used for electronic health records) clinical alert and hand-off communication (up-to-date information regarding patient care, treatment and service, condition, and any recent or anticipated changes). A total of 8 of 20 RN Competency Skill Checks were completed. The DON will continue completing the Competency Skill Checks for the rest of the RNs. Competency Skill Checks will be completed for any RN currently on medical leave or vacation before providing patient care. In-services will be continued by the DON until all licensed staff are re-educated.
6. On 5/9/2025, the facility has created a bowel management tool for significant COCs identifying the need to notify the physician. Starting 05/09/2025, the LNs are responsible for identifying significant COCs on bowel management mentioned below:
a. License nurses will identify Residents who have not had BMs for 72 hours, with new or worsening symptoms, and other associated abnormal changes but not limited to frequency and consistency of bowel, abdominal pain, abdominal distension, decreased peristalsis (digestion of food), and signs of gastrointestinal (GI, refers to the organs of the body that play a part in food digestion) bleeding.
b. Upon identification LNs will utilize the tool and document the notification of the physician.
c. LNs will continue documenting the COCs through the Situation, Background, Assessment, and Recommendation (SBAR) in the clinical health records.
d. LNs will obtain recommendations from the physicians and will carry [the recommendations] out.
e. The tool will be completed daily [during] each shift by the charge nurses, the tool will be collected by medical record staff and retained for review.
7. On 05/09/2025, the medical records team also conducted an audit of the alert system in PCC. The PCC alert notifies the nursing team when a resident does not have BMs for 24 hours or more.
Cross Refence: F641, F842
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 10/24/2022 and readmitted the resident on 1/25/2023 with diagnoses that included psychosis (refers to symptoms that happen when a person is disconnected from reality), muscle wasting, and atrophy (wasting away).
During a review of Resident 1's CP titled, Constipation, initiated on 1/25/2023, reevaluated 4/2025, the CP indicated Resident 1 was at risk for constipation due to medication use and decreased mobility (the ability to move or be moved freely and easily). The CP indicated Resident 1 had a history of constipation. The CP's interventions indicated for LNs to monitor medications that may cause constipation and to notify MD 1 if Resident 1 was unable to relieve constipation.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/7/2025, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene.
During a review of Resident 1's Progress Notes (PN), dated 5/6/2025, timed at 7:51 am, the PN indicated on 5/6/2025, at 6:05 am, Resident 1 complained of not having a BM for two days. The PN indicated Resident 1 complained of abdominal pain (unrated), bloating, and feeling uncomfortable during the night shift (11 pm to 7 am, from 5/5/2025 to 5/6/2025).
During a review of Resident 1's SBAR form, dated 5/6/2025, timed at 8 am, the SBAR indicated Resident 1 had a COC due to constipation or impaction (hardened stool that is stuck in the rectum [the last section of the large intestine, a long, continuous tube that connects to the colon [the longest part of the large intestine] and the anus [the end of the large intestine] due to long lasting constipation). The SBAR indicated Resident 1's last BM was on 5/4/2025. The SBAR indicated RN 3 notified MD 1 regarding Resident 1's constipation and received the recommendation to administer magnesium citrate.
During a review of Resident 1's Physician Telephone Orders (PO), dated 5/6/2025, timed at 10:20 am, the PO indicated to administer magnesium citrate oral solution, give 296 milliliters (ml- unit of measurement) by mouth, one time only, for constipation until 5/6/2025 at 11:59 pm. The PO indicated RN 2 signed the PO.
During a review of Resident 1's Medication Administration Record (MAR, a log initialed and/or signed by the LNs with the date and time a medication was administered to a resident) dated 5/6/2025, timed at 4:38 pm, the MAR indicated LVN 3 administered 296 ml of magnesium citrate oral solution to Resident 1.
During a review of Resident 1's SBAR Communication Form, dated 5/7/2025, untimed, the SBAR indicated Resident 1 had a COC. The SBAR indicated on 5/6/2025 at 10:55 pm, Resident 1 was in bed with Resident 1's eyes closed, and Resident 1 had stable vital signs (VS - measurements of the body's most basic functions such as body temperature, heart rate, respiration rate, and blood pressure are within normal limits). The SBAR indicated at 11:10 pm (on 5/6/2025), Resident 1 was heard, by LVN 4, calling out for O2. The SBAR indicated Resident 1's O2 saturation (sats, percentage of O2 in the blood) was 97 percent (%, unit of measurement) while receiving 3 liters (L, unit of measurement) per minute (LPM, unit of expressed flow rate) of O2 via nasal cannula (NC, a device that delivers extra oxygen through a tube and into the nose). The SBAR indicated Resident 1's abdomen was distended. The SBAR indicated on 5/7/2025 between 12:15 am and 12:30 am, Resident 1 complained of 8 out of 10 pain (severe/intense pain) to Resident 1's abdomen. The SBAR indicated Resident 1 accepted Norco (medication used to treat moderate to severe pain) for abdominal pain. The SBAR indicated MD 1 was notified of Resident 1's expiration (death) on 5/7/2025, at 2 am.
During a review of Resident 1's untitled EMS Report (EMSR), dated 5/7/2025, timed at 1:10 am, the EMSR indicated the facility notified the EMS on 5/7/2025 at 1:10 am. The EMSR indicated the EMTs arrived at the facility on 5/7/2025 at 1:17 am and were with Resident 1 at 1:18 am. The EMSR indicated Resident 1 was found supine (face up), unresponsive, and pulseless (without a heart rate). The EMSR indicated the EMTs administered O2, performed CPR, administered two rounds (doses) of one milligram (mg- unit of measurement) of epinephrine (primary drug administered during CPR used to improve blood flow) for cardiac arrest via intraosseous (IO, insertion of a needle into the bone to deliver fluids, medications, and blood products), and a total of 1000 ml of Intravenous [IV, soft, flexible tube placed inside a vein used to administer fluids and medication directly into the bloodstream] fluids were administered to Resident 1. The EMSR indicated Resident 1 did not have a return of spontaneous circulation (ROSC, when the heart begins to beat on its own and blood circulates after CPR is performed) after 20 consecutive minutes [of CPR]. The EMSR indicated Resident 1's time of death was on 5/7/2025 at 1:42 am.
During a review of Resident 1's PN, dated 5/7/2025, time at 8:25 am, LVN 4 documented (on 5/7/2025) between 1:06 am and 1:09 am, LVN 4 made rounds (visually checking residents) to assess the effectiveness of Resident 1's pain medication (Norco), and LVN 4 found Resident 1 unresponsive. The PN indicated the RN [RN 4] was notified and 9-1-1 was called. The PN indicated resuscitative efforts were immediately initiated while waiting for EMS. The PN indicated (on 5/7/2025), between 1:16 am and 1:42 am, the EMTs arrived, presumed care, and [continued] resuscitative efforts for Resident 1. The PN indicated the EMTs pronounced Resident 1's time of death on 5/7/2025, at 1:42 am.
During a telephone interview on 5/7/2025 at 3:37 pm, with LVN 4, LVN 4 stated on 5/6/2025 at 11:10 pm, Resident 1 asked for an increase in O2 because Resident 1, felt like it was hard to breathe. LVN 4 stated LVN 4 increased Resident 1's O2 from 2 LPM to 3 and a half LPM via NC. LVN 4 stated, on 5/7/2025 at 12:15 am, Resident 1 complained of 8 out of 10 abdominal pain and Resident 1 had abdominal distension. LVN 4 stated Resident 1 received Norco for the abdominal pain. LVN 4 stated, 30 minutes after administering Norco, LVN 4 went to reassess Resident 1's pain, but Resident 1 was found unresponsive. LVN 4 stated Resident 1 had emesis coming out of Resident 1's nose and mouth and went down the sides of Resident 1's face. LVN 4 stated, the emesis was thick, watery, chunky, burgundy and black in color. LVN 4 stated there was, A lot of emesis mixed with blood. LVN 4 stated, It smelled like blood. LVN 4 stated LVN 4 checked Resident 1's carotid (artery [blood vessel that carries blood from the heart to the tissues and organs in the body] located on each side of the neck) and radial (artery located in the wrist) pulses and both pulses were missing. LVN 4 stated Resident 1's eyes did not respond to light. LVN 4 stated LVN 4 immediately started CPR and called a code blue (activation of an alert during a medical emergency such as cardiac arrest). LVN 4 stated LVN 4 informed RN 4 when LVN 4 increased Resident 1's O2 (on 5/6/2025 at 11:10 pm) and when Resident 1 complained of 8/10 abdominal pain, on 7/5/2025 at 12:15 am, because these situations were COCs for Resident 1. LVN 4 stated when Resident 1 experienced a COC, LVN 4 was supposed to assess Resident 1 and notify MD 1. LVN 4 stated LVN 4 only informed RN 4 but did not notify MD 1 of Resident 1's COC.
During an interview on 5/8/2025 at 7:50 am, with CNA 5, CNA 5 stated, on 5/6/2025 at 11 pm, Resident 1 complained Resident 1's whole stomach was hurting. CNA 5 stated CNA 5 touched Resident 1's stomach and it was, rock hard. CNA 5 stated CNA 5 asked LVN 3 and LVN 4 when Resident 1 was going to be sent to the hospital because Resident 1 was requesting to be sent to the hospital. CNA 5 stated LVN 4 responded by stating LVN 4 needed to speak to RN 4 to see what RN 4's opinion was. CNA 5 stated Resident 1 continued to complain of stomach pain throughout the night. CNA 5 stated CNA 5 attempted to make Resident 1 as comfortable as possible within CNA 5's scope of practice (activities and duties that a healthcare professional is permitted to undertake). CNA 5 stated CNA 5 also went to the nurses' station to talk to LVN 4 and RN 4. CNA 5 stated CNA 5 asked LVN 4 and RN 4 if they were going to send Resident 1 out [to the hospital] because Resident 1 did not look like Resident 1 was in good condition. CNA 5 stated LVN 4 told CNA 5 they needed to wait for RN 4's instruction. CNA 5 stated LVN 4 went to check on Resident 1 after administering the pain medication (Norco) and LVN 4 came out of Resident 1's room asking CNA 5 to call 9-1-1. CNA 5 stated CNA 5 called 9-1-1. CNA 5 stated after the EMTs pronounced Resident 1 dead, RN 4 asked CNA 5 to clean Resident 1. CNA 5 stated as soon as CNA 5 walked into Resident 1's room, CNA 5 observed Resident 1's skin was pale, and there was, Black sludge [thick, soft, wet mixture of liquid and solid components], all around Resident 1's head area, bed railing, and all over the floor. CNA 5 stated, It [the emesis] looked like black bean chunks. CNA 5 stated, It [the emesis] smelled rotten [bad smelling]. CNA 5 stated CNA 5 finished cleaning Resident 1, but Resident 1 continued to bleed out of Resident 1's nose.
During a telephone interview on 5/8/2025 at 9:29 am, with LVN 4, LVN 4 stated on 5/6/2025 at 11:10 pm, when LVN 4 increased Resident 1's O2, LVN 4 told RN 4 that LVN 4 wanted to send Resident 1 to the hospital because Resident 1's, Stomach was distended. LVN 4 stated Resident 1's abdomen was, hard. LVN 4 stated Resident 1's abdominal distension, scared, LVN 4 because LVN 4 had cared for Resident 1 the last six months and LVN 4 had never seen Resident 1's stomach look like that (distended). LVN 4 stated, I don't know why Resident 1 was not sent out [to the hospital] earlier for some kind of test. LVN 4 stated, even hours after receiving magnesium citrate, Resident 1's abdomen was still distended and hard. LVN 4 stated LVN 4 called RN 4 a second time on 5/7/2025 between 12:15 am and 12:30 am, to inform RN 4 Resident 1 had 8 out of 10 pain on Resident 1's abdomen. LVN 4 stated RN 4 and RN 5 suggested giving Norco first to Resident 1 for the severe abdominal pain. LVN 4 stated LVN 4 wanted to, Use the chain of command [a formal transfer of authority and responsibility for a unit from one commanding to another] and LVN 4 did not know if it was okay for LVN 4 to call MD 1 or 9-1-1. LVN 4 stated if LVN 4 would have known, It was okay to send Resident 1 to the hospital despite consulting RN 4, LVN 4 would have sent Resident 1 to the hospital because Resident 1's condition was not good. LVN 4 stated, A fully distended, rock-hard stomach doesn't just happen. LVN 4 stated Resident 1 should not have died that quickly. LVN 4 stated Resident 1 should have been sent to the hospital earlier on 5/6/2025.
During a telephone interview on 5/8/2025 at 11:48 am, with RN 4, RN 4 stated, on 5/6/2025 around 11:10 pm, LVN 4 informed RN 4 that Resident 1 needed an increase in O2. RN 4 stated at around 11:30 pm (on 5/6/2025), RN 4 assessed Resident 1 and Resident 1's abdomen was distended and hard to touch. RN 4 stated RN 4 did not auscultate (examination of the resident by listening to bowel sounds to assess for intestinal function) Resident 1's abdomen. RN 4 stated Resident 1 had distension, and a hard to touch, abdomen even after receiving magnesium citrate. RN 4 stated MD 1 should have been notified of Resident 1's COC because Resident 1 had other symptoms beside constipation. RN 4 stated RN 4 needed to notify MD 1 because Resident 1 needed an increase in O2, had abdominal distension, and acute onset of severe abdominal pain. RN 4 stated, there must have been something serious going on with Resident 1. RN 4 stated MD 1 was not notified, and Resident 1 had a rapid decline in condition.
During a telephone interview on 5/8/2025 at 12:36 pm, with RN 3, RN 3 stated on 5/6/2025 at, around 4 am, Resident 1 complained of not having a BM, feeling bloated, and feeling pain (unrated) in the abdomen. RN 3 stated Resident 1 had a distended abdomen. RN 3 stated RN 3 did not assess Resident 1's abdomen, listen to bowel sounds, nor ask Resident 1 the pain level Resident 1 felt in Resident 1's abdomen. RN 3 stated RN 3 informed MD 1 Resident 1 was constipated. RN 3 stated RN 3 did not inform MD 1 of Resident 1's abdominal distension, feeling bloated, or the unrated abdominal pain. RN 3 stated providing all [pertinent] information helped MD 1 determine the treatment needed for Resident 1.
During a telephone interview on 5/8/2025 at 12:57 pm with MD 1, MD 1 stated MD 1 was informed by facility nursing staff (unable to identify) on 5/6/2025 at 7:44 am, Resident 1 was constipated. MD 1 stated MD 1 was notified Resident 1 continued to be constipated even after Resident 1 had received lactulose (synthetic, non-absorbable sugar used primarily as a laxative to treat constipation) and a water enema (procedure where water is introduced into the rectum to cleanse the bowel and treat constipation). MD 1 stated staff requested a KUB (Kidney/Ureter [thin tubular structure that connects the kidneys to the urinary bladder [hollow muscular organ that acts as a reservoir for urine]/Bladder) X-ray (imaging study that takes pictures of the bones and soft tissues), but MD 1 recommended the administration of magnesium citrate first. MD 1 stated facility staff did not inform MD 1 Resident 1 had abdominal distension, severe abdominal pain, and abdominal firmness/hardness. MD 1 stated staff (unidentified) notified MD 1 again on 5/7/2025 at 6:26 am that Resident 1 was found unresponsive, EMS could not achieve ROSC, and Resident 1 passed away (on 5/7/2025 at 1:42 am). MD 1 stated when magnesium citrate was not effective in relieving constipation, pain, abdominal distension, and hardness, LNs needed to contact MD 1 so MD 1 could provide additional orders. MD 1 stated MD 1 would have ordered a KUB X-ray for Resident 1. MD 1 stated when Resident 1 experienced SOB and needed an increase in O2, had severe abdominal pain, and had a distended abdomen, LNs needed to notify MD 1 because Resident 1 needed higher level care. MD 1 stated LNs did not notify MD 1 of Resident 1's symptoms and this [not notifying MD 1 of Resident 1's COC] stopped Resident 1 from receiving higher level care and being treated for those symptoms. MD 1 stated MD 1 was not notified about Resident 1 having coffee ground emesis when Resident 1 was found unresponsive. MD 1 stated coffee ground emesis indicated Resident 1 may have had GI bleeding. MD 1 stated signs and symptoms of GI bleeding included, abdominal distension and pain, decreased bowel sounds, nausea, vomiting, decreased O2 sats, or an increased need for O2.
During a telephone interview on 5/8/2025 at 2:40 pm, with RN 2, RN 2 stated, on 5/6/2025 before 10 am, Resident 1 informed RN 2 Resident 1 did not have a BM for two days. RN 2 stated RN 2 assessed Resident 1 and Resident 1 had hypoactive bowel sounds, abdominal distension, and firmness. RN 2 stated Resident 1 complained of abdominal pain, but RN 2 did not ask/assess Resident 1's pain level. RN 2 stated based on RN 2's assessment of Resident 1, Resident 1 had 7/10 pain (severe pain). RN 2 stated RN 2 did not relay RN 2's assessment to MD 1 because Resident 1's main complaint was constipation. RN 2 stated RN 2 was supposed to inform MD 1 of Resident 1's full assessment because Resident 1's situation could worsen.
During an interview on 5/8/2025 at 4:44 pm with the DON, the DON stated when Resident 1 complained of constipation, LNs were supposed to assess Resident 1's abdomen by listening to bowel sounds, checking for dehydration, (state of having too little water in the body), distension, bloating, and pain. The DON stated the assessment could determine the next steps/interventions to be taken and escalating the assessment findings to MD 1 for new orders. The DON stated if LNs did not relay Resident 1's full assessment and symptoms to MD 1, It could affect Resident 1's treatment and outcome. The DON stated Resident 1's condition may not improve and could worsen. The DON stated when Resident 1 had new symptoms or when symptoms became more severe, MD 1 needed to be notified immediately (instantly) so MD 1 could decide the best course of treatment, provide more medication, or send Resident 1 to the hospital. The DON stated when MD 1 ordered the medication (magnesium citrate) and the medication was not effective, or did not relieve symptoms of constipation, MD 1 needed to be notified.
During a review of the facility's undated P&P titled, Resident Examination and Assessment, the P&P indicated The purpose of the P&P was to examine and assess the resident for any abnormalities in health status, which provided a basis for the CP. The P&P indicated The GI assessment included to assess for: abdominal distension and hardness, constipation, and bowel sounds in all four quadrants (four sides of the abdomen); hypoactive (reduced bowel sounds, can indicate the intestines are not working properly), normal, or hyperactive (increased bowel sounds) sounds. The P&P indicated Notify the physician of any abnormalities such as, but not limited to abnormal vital signs, labored breathing (struggle to breathe), distended, hard abdomen, or absence of bowel sounds, and worsening of pain, as reported by the resident.
During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated The facility promptly notified the resident, his or attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status. The P&P indicated The nurse will notify the resident's attending physician or physician on-call when there has been a(an) significant change in the resident's physician/emotional/mental condition, a need to alter the resident's medical treatment significantly, need to transfer the resident to a hospital or treatment center, and/or specific instructions to notify the physician of changes in the resident's condition. The P&P indicated Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted on the Interact SBAR Communication Form. The P&P indicated The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to examine and assess one of 16 sampled residents (Resident 1) accordi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to examine and assess one of 16 sampled residents (Resident 1) according to the facility's policy and procedure (P&P) titled, and Resident Assessment and Examination, by failing to:
1. Ensure when Resident 1 experienced a change of condition (COC- a change in the resident's health or functioning that requires further assessment and intervention) on [DATE] at 8 am, Registered Nurse 2 (RN 2) and RN 3 assessed Resident 1's abdominal distension (bloating or swelling ), abdominal firmness (abdomen feeling hard or tight to the touch) rebound or guarding (physical signs that can indicate inflammation of the abdominal lining or other acute abdominal issues), bowel sounds (sound produced by the movement of fluid and air in the intestines) for hyperactivity (increased bowel sounds), hypoactivity (reduced bowel sounds) and pain.
2. Ensure RN 5 and Licensed Vocational Nurse (LVN) 3 assessed Resident 1's abdomen and pain on [DATE] between 3 pm and 11 pm when Resident 1's abdominal pain, abdominal distension and abdominal firmness did not after receiving magnesium citrate (laxative) [DATE] at 4:38 pm. Resident 1 was on monitoring for constipation (less frequent bowel movement [BM]).
3. Ensure LVN 3 and LVN 4 assessed Resident 1's oxygen (O2- colorless gas) saturation (sats- percentage of oxygen in the blood) before increasing Resident 1's oxygen to be increased from two liters per minute (LPM- unit of measurement) to three and a half LPM, on [DATE] at 11:10 pm when Resident 1 has shortness of breath.
As a result of these failures, Resident 1 was not provided with a full assessment and had the potential to result in adverse consequences for Resident 1.
Cross Reference: F580 and F842
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage), chronic respiratory failure (a long lasting condition when the lungs cannot get enough oxygen)and muscle wasting and atrophy (thinning of muscle mass).
During a review of Resident 1's care plan (CP) titled, COPD, initiated on [DATE] and reevaluated on 4/2025, the CP indicated Resident 1 was at risk for discomfort, shortness of breath, and exacerbation (worsening) secondary (due to) COPD. The CP interventions indicated Resident 1 to receive O2 at two liters (unit of volume) per minute (LPM) via nasal canula (NC- tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen).
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene. The MDS indicated Resident 1 was always incontinent (inability to control urination and bowel movement [BM]).
During a review of Resident 1's Progress Notes (PN) dated [DATE], timed at 7:51 am, the PN indicated at 6:05 am, Resident 1 complained of not having a BM for two days. The PN indicated Resident 1 complained of abdominal pain (unrated), bloating, and feeling uncomfortable during the night shift (11 pm to 7 am). The PN indicated Resident 1 was on two LPM of O2 via NC.
During a review of Resident 1's eINTERACT SBAR form dated [DATE], timed at 8 am, the SBAR indicated Resident 1 had a COC due to constipation or impaction (hardened stool). The SBAR indicated Resident 1 had constipation and Resident 1 had not had a BM in two to three days. The SBAR indicated RN 3 notified MD 1 and MD 1 ordered magnesium citrate first, before a Kidney Ureter Bladder (KUB-imaging test) and X-ray (imaging study that uses radiation and takes pictures of the inside of the body) were taken. The SBAR form did not indicate Resident 1 had abdominal distention, firmness, or pain.
During a review of Resident 1's SBAR Communication Form dated [DATE], timed at 1:06 am, the SBAR indicated Resident 1 had a COC. The SBAR form did not indicate an abdominal/GI evaluation (assessment). The SBAR indicated on [DATE] at 10:55 pm, Resident 1 was in bed with eyes closed. The SBAR form indicated at 11:10 pm, Resident 1 was heard, by LVN 4, needing O2. The SBAR indicated Resident 1's O2 sat was 97 percent (%) while receiving three LPM of O2 via NC. The SBAR indicated Resident 1's abdomen was distended. The SBAR indicated on [DATE] between 12:15 am and 12:30 am, Resident 1 complained of eight out of 10 pain (pain scale 0 to 10, 0 means no pain and 10 means the worst possible pain felt) to the abdomen. The SBAR indicated Resident 1 received Norco (brand name for hydrocodone-acetaminophen- used to treat moderate to moderate to severe pain).
During a review of Resident 1's PN dated [DATE], time at 8:25 am, LVN 4 documented (on [DATE]) between 1:06 am and 1:09 am, LVN 4 made rounds (visually checking residents) to assess the effectiveness of Resident 1's pain medication (Norco), and LVN 4 found Resident 1 unresponsive. The PN indicated the RN [RN 4] was notified and 9-1-1 was called. The PN indicated resuscitative efforts were immediately initiated while waiting for EMS. The PN indicated (on [DATE]), between 1:16 am and 1:42 am, the EMTs arrived, presumed care, and [continued] resuscitative efforts for Resident 1. The PN indicated the EMTs pronounced Resident 1's time of death on [DATE], at 1:42 am.
During a telephone call on [DATE] at 1:02 pm, [DATE] at 11:47 am, and [DATE] at 12:59 pm, an attempt was made to reach LVN 3, but LVN 3 could not be reached.
During a telephone call on [DATE] at 1:03 pm and on [DATE] at 11:43 am, an attempt was made to reach RN 5, but RN 5 could not be reached.
During a telephone interview on [DATE] at 1:11 pm, with RN 4, RN 4 stated RN 5 did not endorse to RN 4 that Resident 1 had abdominal distension or pain when RN 4 started RN 4's shift on [DATE] at 11 pm.
During a telephone interview on [DATE] at 3:37 pm, with LVN 4, LVN 4 stated on [DATE] at 11:10 pm, Resident 1 asked for an increase in O2 because Resident 1, felt like it was hard to breathe. LVN 4 stated LVN 4 increased Resident 1's O2 from 2 LPM to 3 and a half LPM via NC. LVN 4 stated LVN 4 documented the O2 administration as three LPM. LVN 4 stated LVN 4 did not know what Resident 1's O2 sats were before increasing the O2, and did not assess Resident 1's O2 sats until after increasing Resident 1's O2. LVN 4 stated LVN 3 did not endorse to LVN 4 that Resident 1 had abdominal distension and pain when LVN 4 started the shift on [DATE] at 11 pm. LVN 4 stated LVN 4 informed RN 4 that Resident 1's O2was increased. LVN 4 stated, on [DATE] at 12:15 am, Resident 1 complained of 8 out of 10 abdominal pain and Resident 1 had abdominal distension. LVN 4 stated Resident 1 received Norco for the abdominal pain, and 30 minutes after administering Norco, LVN 4 went to reassess Resident 1's pain, but Resident 1 was found unresponsive. LVN 4 stated LVN 4 informed RN 4 when LVN 4 increased Resident 1's O2 (on [DATE] at 11:10 am) and when Resident 1 complained of 8/10 abdominal pain, on [DATE] at 12:15 am, because these situations were COCs for Resident 1. LVN 4 stated when Resident 1 experienced a COC, LVN 4 was supposed to assess Resident 1 and notify MD 1. LVN 4 stated LVN 4 only informed RN 4 but did not notify MD 1 of Resident 1's COC.
During an interview on [DATE] at 7:30 am, with CNA 5, CNA 5 stated on [DATE] at 11 pm, Resident 1 complained Resident 1's whole stomach was hurting. CNA 5 stated CNA 5 touched Resident 1's stomach and it was, rock hard. CNA 5 stated LVN 3 and LVN 4 increased Resident 1's supplemental O2. CNA 5 stated LVN 3 and LVN 4 did not assess Resident 1's O2 sat level before increasing the O2. CNA 5 stated CNA 5 asked LVN 3 and LVN 4 if Resident 1 was going to be sent to the hospital because Resident 1 was asking to be sent. CNA 5 stated LVN 4 told CNA 5 they needed to wait for RN 4's instruction. CNA 5 stated Resident 1 continued to complain of stomach pain.
During a telephone interview on [DATE] at 11:48 am, with RN 4, RN 4 stated, on [DATE] around 11:10 pm, LVN 4 informed RN 4 that Resident 1 needed an increase in O2. RN 4 stated at around 11:30 pm (on [DATE]), RN 4 assessed Resident 1 and Resident 1's abdomen was distended and hard to touch. RN 4 stated RN 4 did not auscultate (examination of the resident by listening to bowel sounds to assess for intestinal function) Resident 1's abdomen. RN 4 stated Resident 1 had distension, and a Hard to touch, abdomen even after receiving magnesium citrate. RN 4 stated when RN 4 arrived at Resident 1's code (blue), RN 4 observed a moderate amount of coffee-ground emesis on Resident 1's gown and body. RN 4 stated coffee-ground emesis indicated GI bleeding.
During a telephone interview on [DATE] at 12:36 pm, with RN 3, RN 3 stated on [DATE] at, around 4 am, Resident 1 complained of not having a BM, feeling bloated, and pain in the abdomen. RN 3 stated Resident 1 had a distended abdomen. RN 3 stated RN 3 did not assess Resident 1's abdomen, listen to bowel sounds, nor ask Resident 1 the pain level Resident 1 felt in Resident 1's abdomen. RN 3 stated RN 3 informed MD 1 Resident 1 was constipated. RN 3 stated RN 3 did not inform MD 1 of Resident 1's abdominal distension, feeling bloated, or the unrated abdominal pain. RN 3 stated providing all [pertinent] information helped MD 1 determine the treatment needed for Resident 1.
During a telephone interview on [DATE] at 12:57 pm, with MD 1, MD 1 stated MD 1 was informed by facility nursing staff (unable to identify) on [DATE] at 7:44 am, Resident 1 was constipated.
MD 1 stated MD 1 was notified Resident 1 continued to be constipated even after Resident 1 had received lactulose (synthetic, non-absorbable sugar used primarily as a laxative to treat constipation) and a water enema (procedure where water is introduced into the rectum to cleanse the bowel and treat constipation).
During a telephone interview on [DATE] at 2:40 pm, with RN 2, RN 2 stated, on [DATE] before 10 am, Resident 1 informed RN 2 Resident 1 did not have a BM for two days. RN 2 stated RN 2 assessed Resident 1 and Resident 1 had hypoactive bowel sounds, abdominal distension, and firmness. RN 2 stated Resident 1 complained of abdominal pain, but RN 2 did not ask/assess Resident 1's pain level. RN 2 stated based on RN 2's assessment of Resident 1, Resident 1 had severe pain. RN 2 stated RN 2 did not relay RN 2's assessment to MD 1 because Resident 1's main complaint was constipation. RN 2 stated RN 2 was supposed to inform MD 1 of Resident 1's full assessment because Resident 1's situation could worsen.
During an interview on [DATE] at 4:44 pm, with the DON, the DON stated when Resident 1 complained of constipation, licensed nurses were supposed to assess Resident 1's abdomen by listening to bowel sounds, checking for dehydration, distension, bloating, and pain. The DON stated the assessment could determine the next steps to be taken, interventions needed, and escalating the assessment findings to MD 1 for new orders. The DON stated if LNs did not relay Resident 1's full assessment and symptoms to MD 1, It could affect Resident 1's treatment and outcome. The DON stated Resident 1's condition may not improve and could worsen.
During a review of the facility's P&P titled, Resident Examination and Assessment, revised 2/2014, the P&P indicated the purpose of the P&P was to examine and assess the resident for any abnormalities in health status, which provided a basis for the CP. The P&P indicated the GI assessment included to assess for: abdominal distension and hardness, constipation, and bowel sounds in all four quadrants (four sides of the abdomen); hypoactive, normal, or hyperactive sounds. The P&P indicated to notify the physician of any abnormalities such as, but not limited to abnormal vital signs, labored breathing, distended, hard abdomen, or absence of bowel sounds, and worsening of pain, as reported by the resident.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure accurate and complete documentation for one of one sampled resident (Resident 1), in accordance with the facility's policies and pro...
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Based on interview and record review, the facility failed to ensure accurate and complete documentation for one of one sampled resident (Resident 1), in accordance with the facility's policies and procedures (P&P) titled, Charting and Documentation and Change in a Resident's Condition or Status.
This deficient practice resulted in no documentation of Resident 1's full assessments during a Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions) on 5/6/2025
and had the potential to result in complications leading to a physical decline to Resident 1.
Cross Reference: F580 and F641
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 10/24/2022 and readmitted the resident on 1/25/2023 with diagnoses that included psychosis (refers to symptoms that happen when a person is disconnected from reality), muscle wasting, and atrophy (wasting away).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/7/2025, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene.
During a review of Resident 1's Medication Administration Record (MAR, a log initialed and/or signed by the licensed nurse with the date and time a medication was administered to a resident) dated 5/5/2025 to 5/7/2025, the MAR did not indicate Resident 1 had pain.
During a review of Resident 1's Progress Notes (PN), dated 5/6/2025, timed at 7:51 am, the PN indicated at 6:05 am, Resident 1 complained of not having a BM for two days. The PN indicated Resident 1 complained of abdominal pain (unrated), bloating, and feeling uncomfortable during the night shift (11 pm to 7 am). The PN indicated Resident 1 was on two LPM of O2 via NC.
During a review of Resident 1's eINTERACT SBAR form dated 5/6/2025, timed at 8 am, the SBAR indicated RN 3 documented Resident 1 had a COC due to constipation. The SBAR form did not indicate Resident 1 had abdominal distention, firmness, bloating, or pain.
During a review of Resident 1's PN dated 5/6/2025 between 3 pm and 11 pm, the PN did not indicate an abdominal/GI evaluation (assessment) was completed.
During a review of Resident 1's SBAR Communication Form, dated 5/7/2025, timed at 1:06 am, the SBAR indicated Resident 1 had a COC. The SBAR indicated on 5/6/2025 at 10:55 pm, Resident 1 was in bed with eyes closed. The SBAR indicated at 11:10 pm, Resident 1 was heard, by LVN 4, calling out for O2. The SBAR indicated Resident 1's O2 sats was 97 percent (%, unit of measurement) while receiving 3 LPM of O2 via NC. The SBAR indicated Resident 1's abdomen was distended. The SBAR indicated on 5/7/2025 between 12:15 am and 12:30 am, Resident 1 complained of 8 out of 10 pain (severe pain) to the abdomen. The SBAR indicated a GI (gastrointestinal, refers collectively to the organs of the body that play a part in food digestion [breakdown of food]) evaluation was not done for Resident 1 (section left blank). The SBAR did not indicate Resident 1 was found with coffee-ground emesis (vomiting).
During a telephone interview on 5/7/2025 at 3:37 pm, with LVN 4, LVN 4 stated on 5/6/2025 at 11:10 pm, Resident 1 asked for an increase in oxygen [O2, colorless, odorless gas] because Resident 1, felt like it was hard to breathe. LVN 4 stated LVN 4 increased Resident 1's O2 from 2 liters per minute (LPM, unit of expressed flow rate) to 3 and a half LPM via nasal canula ([NC] a device-lightweight flexible plastic tubing used to deliver supplemental oxygen, tubing ending is placed in the nostrils and is fitted over the patient's ears). LVN 4 stated LVN 4 documented 3 LPM instead of 3 and a half LPM. LVN 4 stated LVN 4 was supposed to document Resident 1's oxygen saturation (measurement that indicates what percentage of blood saturated with oxygen) accurately, so it reflected Resident 1's condition correctly.
During a telephone interview on 5/8/2025 at 9:29 am, with LVN 4 stated LVN 4 forgot to document Resident 1's 8 out of 10 pain (pain scale 0 to 10, 0 means no pain and 10 means the worst possible pain felt) in Resident 1's MAR and document Resident 1 had coffee-ground emesis. LVN 4 stated it was important to ensure all LVNs documented accurately to reflect Resident 1's condition.
During a telephone interview on 5/8/2025 at 12:36 pm, with RN 3, RN 3 stated on 5/6/2025 at, around 4 am, Resident 1 complained of not having a BM, feeling bloated, and feeling pain (unrated) in the abdomen. RN 3 stated Resident 1 had a distended abdomen.
RN 3 stated RN 3 did not document Resident 1 feeling bloated and feeling pain (unrated) in Resident 1's SBAR form dated 5/6/2025, timed at 8 am. RN 3 stated documenting in the medical record helped physicians determine the treatment needed for Resident 1, and the physician orders needed.
During a telephone interview on 5/8/2025 at 2:40 pm, with RN 2, RN 2 stated, on 5/6/2025 before 10 am, Resident 1 informed RN 2 Resident 1 did not have a BM for two days. RN 2 stated RN 2 assessed Resident 1 and Resident 1 had hypoactive bowel sounds, abdominal distension, and firmness. RN 2 stated Resident 1 complained of abdominal pain. RN 2 stated based on RN 2's assessment of Resident 1, Resident 1 had severe pain. RN 2 stated, RN 2 did not document the assessment, including Resident 1's pain, performed on Resident 1 in Resident 1's medical record.
During an interview on 5/8/2025 at 4:44 pm, with the DON, the DON stated when Resident 1 complained of constipation, licensed nurses were supposed to assess Resident 1's abdomen. The DON stated the importance of documenting the full assessment when Resident 1 had a COC (5/6/2025) was so that all staff were aware of what [treatment] was done for Resident 1. The DON stated if documentation was missing it affected the residents' care. The DON stated that clinical documentation can greatly impact care because of the feedback in assessment and how that information is relayed to the physician.
During a review of the facility's P&P titled, Charting and Documentation, revised 7/2017, the P&P indicated that all services provided to the resident, progress towards the CP goals, or changes in the resident's medical, physical, functional pr psychosocial condition, shall be documented in the resident's medical record. The P&P the medical record should facilitate communication between the Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents) regarding the resident's condition and response to care. The P&P indicated objective (not opinionated or speculative) observations, medications administered, treatments or serviced performed, changes in the resident's condition, events, incidents or accidents involving the resident, and progress toward or changes in the CP goals and objectives were to be documented in the medical record. The P&P indicated documentation in the medical record will be objective, complete, and accurate. The P&P indicated documentation of procedures and treatments would include care-specific details including the assessment data and/or any unusual findings obtained during the procedure/treatment and how the resident tolerated the procedure/treatment.
During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
Apr 2025
5 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced ...
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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 care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality for four of 67 sampled residents (Residents 2, 5, 11 and 14) as indicated in the facility's policies and procedures (P&P) by failing to:
a. Ensure Resident 2 was not awakened inappropriately early in the morning by a loud noise from the licensed nurse and the light was turned on in Resident 2's room.
b. Ensure Resident 5's urinal receptacle (a container used to hold bodily waste) was kept clean and labeled with Resident 5's name.
c1. Ensure staff (general) were not rude whenever they answered Resident 11's call light and disrespectful whenever they spoke to Resident 11.
c2. Ensure staff (general) did not joked around loudly outside Resident 11's room while Resident 11 was taking a nap.
d. Ensure Resident 14 was not sitting in the hallway in a wheeled recliner chair with only a short-sleeved shirt and an incontinence brief.
These failures resulted in Resident 2 verbalizing feeling scared in her environment, Resident 5 verbalizing feelings of disgust, Resident 11 verbalizing feeling horrible and unimportant, and the potential to result in Resident 14's bodily privacy being violated.
Findings:
a. During a review of Resident 2's admission Record, dated 4/23/2025, the admission Record indicated Resident 2 was readmitted on [DATE] with diagnoses that included ESRD (End Stage Renal Disease -irreversible kidney failure), dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and anxiety disorder (persistent feeling of dread or panic that can interfere with daily life).
During a review of Resident 2's History and Physical (H&P), dated 1/25/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) assessment, dated 8/16/2024, the MDS indicated Resident 2 had intact cognition and lower extremity (hip, knee, ankle, foot) impairment on both sides.
During a review of Resident 2's Physician Order, dated 4/8/2025 at 4:03 pm, the physician order indicated Resident 2 had an order to monitor for emotional distress every shift for 72 hours.
During a review of Resident 2's SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 4/9/2025 at 8:00 am, the SBAR indicated during morning medications Resident 2 complained that LVN 8 woke her without turning on the light and she was startled. The SBAR indicated, Resident 2 stated LVN 8 was screaming at her and she was scared thinking LVN 8 was a ghost. The SBAR further indicated, behavioral changes of increased anxiety.
During an interview on 4/22/2025 at 4:00 pm with Resident 2, Resident 2 stated that on 4/9/2025 at 4 am she was awakened (not in the usual manner) by a loud noise from Licensed Vocational Nurse 8 (LVN 8). Resident 2 stated, the room was dark, she was unable to communicate as her speaking valve was not connected to her tracheostomy (incision made in the windpipe to relieve an obstruction to breathing), and she was scared by the sound. Resident 2 stated, she believed a hand was in front of her face and by her neck but couldn not see who was at her bedside. Resident 2 stated, she tried to push and bang on her bed rail with her right hand to get help for herself because she thought she was having a nightmare. Resident 2 stated, because of this she felt unsafe in her environment.
During an interview on 4/22/2025 at 4:29 pm with Resident 2's roommate, Resident 7, Resident 7 stated the incident occurred when she was asleep in bed and heard LVN 8 make a loud rooster crow. Resident 7 stated she was unsure what was happening but could see Resident 2 moving both arms and could tell she was afraid and trying to get away from something. Resident 7 stated, she asked LVN 8 what was happening and requested her light be turned on. Resident 7 stated, she asked LVN 8 why he did that after he turned on the light but received no response. Resident 7 stated, Resident 2 was crying and was in shock after the incident.
During an interview on 4/23/2025 at 12:35 pm with Licensed Vocational Nurse 11 (LVN 11), LVN 11 stated nurses should knock before entering and when waking a resident, the nurse should do it as gently as possible, to prevent startling them, then announce yourself and your purpose.
During an interview on 4/23/2025 at 3:51 pm with the Quality Assurance Nurse (QAN), QAN stated if the resident was sleeping the nurse could tap them and if the resident was still asleep, they could leave the resident and come back after ensuring the resident was okay. QAN stated it was important to wake them gently so they are not shocked when awakened and as a courtesy to the resident because this was the residents' home.
During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2001, the P&P indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated, residents are treated with dignity and respect at all times.
b. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and Rheumatoid Arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility).
During a review of Resident 5's MDS, dated [DATE], indicated Resident 5 had intact cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 5 required maximal assistance (helper does more than half the effort to lift or hold trunk or limbs and provides more than half the effort) for toileting, showering, personal hygiene, sit to lying, and lying to sitting on side of bed. The MDS indicated Resident 5 required partial assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs, but provides less than half the effort) to perform oral hygiene and upper body dressing, and to roll left and right. The MDS indicated Resident 5 required supervision (helper provides verbal cues and or touching as resident competes activity. Assistance may be provided throughout the activity or intermittently) for eating, and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for lower body dressing, putting on/off footwear, and chair to bed transfer.
During a concurrent observation and interview on 4/21/2025 at 10:34 AM with Resident 5 in Resident 5's room, Resident 5 was laying down in his bed, head of bed was elevated, and two (2) urinal receptacles with a small amount of urine residual and foamy substance inside the receptacle were hanging from the left side of the bed rails, unlabeled. Resident 5 stated the staff does not clean out his urinal receptacles and although they put the lid on them, he can still smell his own urine throughout the day and it makes him feel disgusted by it. Resident 5 stated he has communicated with the staff on how to properly dispose of the urine but they do not listen to him.
During an interview on 4/21/2025 at 10:51 AM with Certified Nursing Assistant 1 (CNA1), the CNA1 stated the facility's policy for handling and cleaning the urinals is to label it with some kind of resident identifier such as the room number, empty the urine, rinse it with water, dump the water, dry it and hang it back on the bed rail. The CNA1 stated no label to identify the urinal belonged to Resident 5. CNA 1 also stated there was urine residual left on the containers and needed to be cleaned. CNA 1 stated she emptied out the urinal earlier.
During an interview on 4/21/2025 at 11:19 AM, with the Director of Staff Development (DSD), the DSD stated residents' urinals should be emptied when its half full, changed if it looks dirty, and it should have a resident name written on it because sometimes there is room changes which could cause an identification error. The DSD stated it was unacceptable to leave behind urine residual because it can affect how residents feel about seeing their own bodily waste affecting their psychosocial well-being.
During a review of the facility's policy and procedure (P&P) titled Bedpan/Urinal, offering/removing, dated February 2018, indicated staff assistance with a urinal should remove the urinal from the bedside, clean the urinal and be sure that it is clean and dry.
During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care items and Equipment, dated October 2018, indicated single resident-use items such as urinals and bedpans are cleaned/disinfected between uses and disposed of afterwards.
During a review of the facility's P&P titled Dignity dated February 2021, indicated staff are expected to promote dignity and assist residents by helping the resident to keep urinary items covered.
c1. During a review of Resident 11's Face Sheet (FS), the FS indicated Resident 11 was admitted to the facility on [DATE] for post care of the right and left thighbone fracture (a partial or complete break in the bone) and for post care of fracture of multiple ribs on the left side. The FS indicated Resident 11 was self-responsible (accountable for their own actions and decisions).
During a review of Resident 11's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 12/20/2024, the H&P indicated Resident 11 had the capacity to understand and make decisions.
During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 required setup or clean-up assistance (helper sets up or cleans up and resident completes activity) in eating, required supervision or touching assistance (helper provides verbal cues and/or touching /steadying and/or contact guard assistance as resident completes activity) with upper body dressing, and required partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, lower body dressing, putting on/taking off footwear, with personal hygiene, and to shower/bathe self,
c2. During an interview on 4/22/2025 at 3:41 pm with Resident 11 inside Resident 11's room, Resident 11 stated staff (general) treat Resident 11 and other residents (unknown) like a nuisance and an irritant. Resident 11 stated 90 percent of facility staff, including kitchen staff, had a bad attitude and did not talk to residents with respect. Resident 11 stated whenever Resident 11 put on the call light, staff would answer the call light and say what happened instead of asking nicely if Resident 11 needed anything. Resident 11 stated Staff joked around loudly outside of Resident 11's door while Resident 11 was taking a nap, and did not care if they woke up Resident 11. Resident 11 stated the staff attitude and how staff treat Resident 11 made Resident 11 feel horrible and made Resident 11 feel like Resident 11 was not important.
d. During a review of Resident 14's FS, the FS indicated Resident 14 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (brain disease, damage, or malfunction caused by an illness or organs that are not working as well as they should) and parkinsonism (brain conditions that cause slowed movements, rigidity [stiffness] and tremors).
During a review of Resident 14's H&P, dated 12/7/2024, the H&P indicated Resident 14 did not have the capacity to understand and make decisions.
During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 was dependent (helper does all the effort) on others for eating, oral hygiene, toileting hygiene, personal hygiene, upper and lower body dressing, and to shower/bathe.
During an observation on 4/22/2025 at 4:32 pm, Resident 14 was observed in the hallway sitting in a wheeled recliner chair with only a short-sleeved shirt and an incontinence brief on.
During a concurrent observation and interview on 4/22/2025 at 4:35 pm with Licensed Vocational Nurse (LVN) 2, LVN 2 approached Resident 14 and covered Resident 14 with a sheet. LVN 2 stated it was important for residents to have pants on when Resident 14 was out of Resident 14's room for privacy amd dignity.
During an interview on 4/22/2025 at 4:38 pm with Certified Nursing Assistant (CNA) 1, CNA 1 stated it was not acceptable for residents to not have pants when they were out of bed for their dignity and privacy.
During an interview on 4/24/2025 at 10:38 am with the Director of Staff Development (DSD), the DSD stated staff must approach and talk to residents with respect and with a respectful tone and modulation of voice. Staff must not sound mad when answering a resident's call light and ask the resident nicely if they needed help. The DSD stated residents must have pants on and/or clothing that covers them up to their knees when out of bed and still have a blanket or sheet to cover them.
During an interview on 4/24/2025 at 2:20 pm with CNA 6, CNA 6 stated CNA 6 got Resident 14 up out of bed on 4/22/2025. CNA 6 stated CNA 6 put pants on Resident 14, but Resident 14 removed them. CNA 6 stated CNA 6 tried to put pants on Resident 14 again, but Resident 14 removed them again, so CNA 6 covered Resident 14 with a blanket. CNA 6 stated residents should not be exposed and show any part of their body for privacy. CNA 6 stated residents must have a gown on and/or a blouse and pants on whenever they were outside their room. CNA 6 stated staff must talk to residents with respect and in a nice way.
During an interview on 4/24/2025 at 3:26 pm with the Director of Nursing (DON), the DON stated staff must be compassionate and respond to residents with a good approach for residents' dignity. The DON stated residents had to be fully dressed and fully covered when out of bed for their dignity and privacy.
During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2001, the P&P indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated, residents are treated with dignity and respect at all times.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure that 59 of 67 sampled residents (Resident 2, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 15, Re...
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Based on interview and record review, the facility failed to ensure that 59 of 67 sampled residents (Resident 2, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 66, and Resident 67) who required assistance with activities of daily living (ADLs-tasks of everyday life such as bathing dressing, and toileting) were provided care and received assistance with showering/bathing in accordance with the residents' care plan and the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting.
These failures resulted in 59 residents not receiving assistance with ADLs as needed and had the potential to affect the residents' well-being.
Findings:
During a review of the Face Sheet (FS - front page of the chart that contains a summary of basic information about the resident) of Resident 2, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 66, and Resident 67, the FS indicated the residents were admitted to the facility with diagnoses which included respiratory failure (when the lungs cannot get enough oxygen into the blood or remove carbon dioxide [waste gas made in the body's cells] from the blood) and had a tracheostomy tube.
During a review of the Minimum Data Set (MDS - a resident assessment tool) for Resident 2, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 66, and Resident 67, the MDS indicated the residents were either dependent (helper does all the effort) on staff or required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, to shower/bathe, and to get in and out of a tub/shower and/or to transfer to and from a bed to a chair or wheelchair.
During a review of the care plan for Resident 2, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 66, and Resident 67, the care plan which focused on the residents' deficit to perform ADL care on their own indicated to provide the residents with assistance with ADLs as needed.
During an interview on 4/23/2025 at 10:43 am with Licensed Vocational Nurse (LVN) 3, LVN 3 stated in the subacute, LVNs on each shift would get 2 residents to provide total care for in addition to passing medications, doing daily charting, and doing any change of condition assessment. LVN 3 stated The Registered Nurses (RNs) assisted with calling the doctor and family and receiving and carrying out physician orders. LVN 3 stated there was always a shower nurse who did all the showers every time LVN 3 worked. LVN 3 stated Certified Nursing Assistants (CNAs) on the day shift usually have 10 residents each, but it depends on how many CNAs were working. LVN 3 stated LVN 3 have heard some CNAs say that they could not get their residents up for a shower because they were busy. LVN 3 stated the least number of CNAs that LVN 3 had seen on the day shift was four (4) and most was six (6).
During an interview on 4/23/2025 at 11:29 am with CNA 2, CNA 2 stated CNA 2 had 12 residents on the day shift and there was no shower nurse that day. CNA 2 stated whenever CNAs had 12 residents on the day shift, the CNAs get overwhelmed with trying to change the residents and showers would not be provided. CNA 2 stated if there was a shower nurse, then showers would be provided.
During an interview on 4/23/2025 at 11:56 am with CNA 3, CNA 3 stated CNA 3 just started working as a shower nurse but also worked as a CNA on the night shift. CNA 3 stated there was supposed to be a shower nurse assigned on the day shift and the evening shift. CNA 3 stated the shower nurse did all the showers scheduled on the shift they were working. CNA 3 stated most of the time the CNA scheduled to work as a shower nurse would get pulled to work on the floor and take an assignment because we are really short (staffed). CNA 3 stated usually there were four CNAs on the floor. CNA 3 stated if there were five CNAs scheduled, then there would be a shower nurse. CNA 3 stated that when there are four CNAs working, the showers would not be done because scheduling the showers would get tricky. CNA 3 stated there was only one shower room for residents who did not have a history of Candida auris (C. auris, a fungal infection which can cause severe illness and spread easily) and that one shower room was used by both station 1 and station 2 (subacute). CNA 3 stated there was another shower room dedicated only for residents with the history of C. auris. CNA 3 stated it also would get tricky to give showers to residents in the subacute because the Respiratory Therapist (RT) had to assist with showers and CNAs had to wait for RTs and the shower room to become available. CNA 3 stated if all the CNAs were going to give showers, then it would make it difficult to schedule the showers. If there was only one person giving showers, then it would be easier to schedule a shower. CNA 3 stated having more shower rooms would also help. CNA 3 stated short staffing was usually caused by staff call offs. CNA 3 stated the only place to document that a shower was provided to a resident was on the Shower Sheet. CNA 3 sated a Shower Sheet would be completed after each shower and put in the binder in the nurses' station. The Shower Sheets were collected by the Director of Staff Development (DSD) every day. CNA 3 stated CNA 3 had worked with only 2 CNAs on the night shift previously. CNA 3 stated that with only 2 CNAs working, CNAs wouldn't be able to reposition residents every 2 hours and if the resident had a urinary catheter, the resident would only be changed once in the shift. CNA 3 stated, even with 4 CNAs in the subacute, it would be hard to provide a shower to the residents because it subacute residents have tracheostomies, G-tubes, needed total care, and were mostly residents were nonverbal.
During an interview on 4/23/2025 at 1:16 pm with CNA 4, CNA 4 stated CNA 4 usually providing care for10 - 14 residents on the day shift in the subacute unit. CNA 4 stated with 10-14 residents, CNA 4 would not be able to provide showers to the residents unless there was a shower nurse.
During an interview on 4/23/2025 at 1:54 pm with CNA 5, CNA 5 stated CNA 5 occasionally providing care for 12 -14 residents on the day shift when short staffed, but normally CNA 5 would providing care for 9-10 residents on the day shift. CNA 5 stated staff calling-offs cause a shortage of staff and when CNAs providing care for 12 -14 residents then care would be affected. CNA 5 stated that when there is not enough CNAs, the shower nurse would get pulled to work on the floor with an assignment and CNA 5 would not have enough time to give showers to the residents. CNA 5 stated CNA 5 would try to provide a bed bath instead of a shower but could not always provide a bed bath. CNA 5 stated in the subacute unit, CNAs were supposed to provide oral care to residents twice a shift but whenever CNA 5 had 12 -14 residents CNA 5 could only provide oral care once a shift.
During an interview on 4/23/2025 at 2:39 pm with Resident 8 stated Resident 8's shower days are on Sundays and Thursdays. Resident 8 stated for the past two weeks, Resident 8 had not had a shower or a bed bath on Thursdays. Resident 9 stated showers were not provided because CNAs would say they were short staffed. Resident 8 stated call lights sometimes not answered for 5 hours on the night shift. Resident 8 stated sometimes CNAs on the night shift would not come around until 4 am because they were short staffed. Resident 8 stated Resident 8 usually turned on the call light to be changed.
During an interview on 4/23/2025 at 3:32 pm with Resident 7, Resident 7 stated when they were short staffed, Resident 7 would only recieved shower once a week. Resident 7 stated that when they were short staffed on the night shift, it would sometimes take an hour to answer the call light, and staff would only come once during the night. Resident 7 stated it had been a while since Resident 7 had two showers in a week because they were short staffed.
During a concurrent interview and record review on 4/24/2025 at 10:38 am with the Director of Staff Development (DSD), the nurse staffing and assignment for the day shift (7 am to 3 pm), the evening shift (3 pm to 11 pm), and the night shift (11 pm to 7 am) from 4/7/2025 to 4/21/2025 in the subacute unit were reviewed. The DSD stated the facility staffing was not short. The DSD stated they schedule enough staff on each shift for the day and go from there. The DSD stated they had to make sure they are meeting the State staffing hours and staff to resident ratio per day and that there are enough staff to provide care to the residents. The DSD stated they also schedule a shower nurse on the day shift and on the evening shift in the subacute to ensure showers are being provided to the residents. The DSD stated when there is a call off, they sometimes pull the shower nurse to cover the assignment of the person who called off. The main goal is for all the needs of the residents to be met and provided. The DSD stated LVNs in the subacute unit were also assigned to two residents, each shift to provide patient care to which lessen the number of residents assigned to the CNAs. The DSD stated the staffing goal in the subacute was to have 6 LVNs each shift, 5 CNAs on the day shift, 4-5 CNAs on the evening shift, and 3-4 CNAs on the night shift. The DSD also stated the shower sheets for the subacute were collected by the subacute staffer (person who makes the nurse staffing schedule for the subacute) every day. The DSD stated if there was no shower sheet completed then there was no way to prove that the resident received a shower because that was how showers and bed baths were documented by the CNAs, and the licensed nurses had to sign the shower sheet. The DSD reviewed the nurse staffing and assignment for the day shift (7 am to 3 pm), the evening shift (3 pm to11 pm), and the night shift (11 pm to 7 am) from 4/7/2025 to 4/21/2025 in the subacute. The review of the nurse staffing and assignment indicated that the LVNs on each shift were not always assigned to two residents to provide patient care. The review of the nurse staffing and assignment indicated the following:
a. 4/7/2025 - Day shift - Census of 58. 5 Certified Nursing Assistants (CNAs) were scheduled to work, but 1 CNA called off. 4 CNAs worked with 11 residents each and there was no shower nurse (a CNA assigned to provide all resident showers scheduled for the shift) assigned. No shower was provided. The residents who were not provided with showers according to the Shower Schedule and the facility census for 4/7/2025 were Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, and Resident 26.
b. 4/7/25 - Evening shift - Census of 57. 4 CNAs worked; 3 CNAs had 11 residents, and 1 CNA had 10 residents. Ther was no shower nurse. The residents who were not provided with showers were Resident 5, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, and Resident 34.
c. 4/9/25 - Evening shift - Census of 59. 4 CNAs worked with 11 to 12 residents each. There was no shower nurse. No shower was provided. The residents who were not provided with showers were Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, and Resident 42.
d. 4/10/25 - Day shift - Census of 59. No CNA called off. 4 CNAs worked with 1 orientee and no shower nurse. 4 CNAs had 12 residents each. No shower was provided. The residents who were not provided with showers were Resident 17, Resident 18, Resident 29, Resident 30, Resident 38, Resident 8, and Resident 26.
e. 4/10/25 - Night shift - Census of 59. 2 CNAs called off and 2 CNAs worked. 1 CNA had 21 residents, and 1 CNA had 20 residents.
f. 4/11/25 - Day shift - Census of 60. 4 CNAs worked with no shower nurse. 2 CNAs had 12 residents, and 2 CNAs had 11 residents each. No call off and no shower nurse. No shower was provided. The residents who were not provided with showers were Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, and Resident 6.
g. 4/11/25 Evening shift - Census of 60. 4 CNAs worked. 2 CNAs had 12 residents, 1 CNA had 10 residents, and 1 CNA with 11 residents. No shower nurse. No shower was provided. The residents who were not provided with showers were Resident 52, Resident 31, Resident 53, Resident 54, Resident 15, Resident 16, Resident 55, Resident 56, Resident 57, and Resident 58.
h. 4/12/25 Night shift - Census of 61. 3 CNAs worked with 17 residents each.
i. 4/13/25 - Day shift - Census of 61. 4 CNAs worked. 3 CNAs had 12 residents, and 1 CNA had 13 residents. The shower nurse called off and was not replaced. No shower was provided. The residents who were not provided with showers were Resident 2, Resident 7, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 38, Resident 8, and Resident 66.
j. 4/15/25 - Day shift - Census of 58. 4 CNAs with no shower nurse. CNAS had 12 residents each. No shower was provided. The residents who were not provided with showers were Resident 44, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, and Resident 6.
k. 4/17/25 - Evening shift - Census of 57. 3 CNAs worked and had 14 residents each. No shower nurse. No shower was provided. The residents who were not provided with showers were Resident 27, Resident 21, Resident 4, Resident 9, Resident 67, Resident 32, Resident 33, Resident 5, and Resident 34.
l. 4/18/25 - Day shift - Census of 57. 4 CNAs worked. 3 CNAs had 11 residents and 1 had 12 residents. No shower nurse. No shower was provided. The residents who were not provided with showers were Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, and Resident 6.
m. 4/18/25 - Evening - Census of 57. 5 CNAs worked with no shower nurse. 3 CNAs had 8 residents and 2 CNAs had 9 residents. No shower was provided. The residents who were not provided with showers were Resident 52, Resident 31, Resident 53, Resident 54, Resident 15, Resident 16, Resident 55, Resident 56, Resident 57, and Resident 58.
n. 4/20/25 - Day shift - Census of 57. 3 CNAs worked with no shower nurse. 3 CNAs had 16 residents each. 2 CNAs called off and 1 CNA was a no call no show. No showers provided. The residents who were not provided with showers were Resident 2, Resident 7, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 38, Resident 8, and Resident 66.
o. 4/21/25 - Day shift - Census of 57. 4 CNAS worked. 1 CNA was a no call no show. No shower nurse was on duty because the shower nurse called off. 3 CNAs had 14 residents, and 1 CNA had 15 residents. There was no shower provided to the residents. The residents who were not provided with showers were Resident 17, Resident 18, Resident 19, Resident 20, Resident 29, Resident 30, Resident 22, Resident 23, Resident 24, Resident 25, and Resident 26.
During an interview on 4/24/2025 at 3:26 pm with the Director of Nursing (DON), the DON stated no matter what, the facility must provide care and showers for the residents as part of accommodating the residents' needs. The DON stated not getting a shower could affect the overall well-being of the residents and not enough staffing should not be an excuse for not providing showers or care for residents.
During a review of the facility P&P titled Activities of Daily Living (ADLs) Supporting, dated March 2018, the P&P indicated, appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the plan of care .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide sufficient nurse staffing for 16 of 45 shifts staffing reviewed in the subacute unit (specific unit in the facility where residents...
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Based on interview and record review, the facility failed to provide sufficient nurse staffing for 16 of 45 shifts staffing reviewed in the subacute unit (specific unit in the facility where residents with a tracheostomy tube [a tube inserted in a surgically created hole in the windpipe to provide an alternative airway for breathing] and residents on a ventilator [a medical device to help support or replace breathing] stayed) to provide care and assistance to 59 of 67 sampled residents in accordance with the facility's policy and procedure (P&P) titled, Staffing, and Facility Assessment, and the facility's Facility Assessment, (FA- a guide used by the facility to evaluate what resources are necessary to care for the facility's residents) and staffing goal for the subacute unit when:
1. Showers were not provided for 59 residents (Resident 2, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 66, and Resident 67).
2. The call light (a device used by a resident to signal their need for assistance from staff) for Resident 7 and Resident 8 was not answered promptly on the night shift (11 pm to 7 am).
These failures had the potential to result in a decline in the residents' physical and psychosocial well-being due to poor quality of care.
Findings:
During a review of the Face Sheet (FS - front page of the chart that contains a summary of basic information about the resident) of Resident 2, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 66, and Resident 67, the FS indicated the residents were admitted to the facility with diagnoses which included respiratory failure (when the lungs cannot get enough oxygen into the blood or remove carbon dioxide [waste gas made in the body's cells] from the blood) and had a tracheostomy tube.
During a review of the Minimum Data Set (MDS - a resident assessment tool) for Resident 2, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 66, and Resident 67, the MDS indicated the residents were either dependent (helper does all the effort) on staff or required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering/bathing, getting in and out of a tub/shower, and/or transferring to and from a bed to a chair or wheelchair.
During an interview on 4/23/2025 at 10:43 am with Licensed Vocational Nurse (LVN) 3, LVN 3 stated in the subacute, LVNs on each shift would get 2 residents to provide total care for, in addition to passing medications, doing daily charting, and doing any change of condition assessment. LVN 3 stated the Registered Nurses (RNs) assisted with calling the doctor and family and receiving and carrying out physician orders. LVN 3 stated there was always a shower nurse who did all the showers every time LVN 3 worked. LVN 3 stated Certified Nursing Assistants (CNAs) on the day shift usually had 10 residents each, but it depended on how many CNAs were working. LVN 3 stated LVN 3 heard some CNAs (unidentified) verbalized that they could not get their residents up for a shower because they (CNAs) were busy. LVN 3 stated the least number of CNAs that LVN 3 had seen on the day shift was four (4) and most was six (6).
During an interview on 4/23/2025 at 11:29 am with CNA 2, CNA 2 stated CNA 2 had 12 residents on the day shift and there was no shower nurse that day. CNA 2 stated whenever CNAs had 12 residents on the day shift, the CNAs would get overwhelmed with trying to change the residents and showers would not be provided. CNA 2 stated if there was a shower nurse, then showers would be provided.
During an interview on 4/23/2025 at 11:56 am with CNA 3, CNA 3 stated CNA 3 just started working as a shower nurse but also worked as a CNA on the night shift. CNA 3 stated there was supposed to be a shower nurse assigned on the day shift and the evening shift. CNA 3 stated the shower nurse did all the showers scheduled on the shift they were working. CNA 3 stated most of the time the CNA scheduled to work as a shower nurse would get pulled to work on the floor and take an assignment because, we are really short (staffed). CNA 3 stated usually there were 4 CNAs on the floor. CNA 3 stated if there were five (5) CNAs scheduled, then there would be a shower nurse. CNA 3 stated when there were four CNAs working, the showers would not be done because scheduling the showers would get tricky. CNA 3 stated there was only one shower room for residents who did not have a history of Candida auris (C. auris, a fungal infection which can cause severe illness and spread easily) and that one shower room was used by both station 1 and station 2 (subacute). CNA 3 stated there was another shower room dedicated only to residents with a history of C. auris. CNA 3 stated it also would get tricky to give showers to residents in the subacute because the Respiratory Therapist (RT) had to assist with showers and CNAs had to wait for the RT and the shower room to become available. CNA 3 stated if all the CNAs were going to give showers, then it would make it difficult to schedule the showers. If there was only one person giving showers, then it would be easier to schedule a shower. CNA 3 stated having more shower rooms would also help. CNA 3 stated short staffing was usually caused by staff call offs. CNA 3 stated the only place to document that a shower was provided to a resident was on the Shower Sheet. CNA 3 stated a Shower Sheet would be completed after each shower and filed in the binder in the nurses' station. The Shower Sheets were collected by the Director of Staff Development every day. CNA 3 stated CNA 3 had worked with only 2 CNAs on the night shift previously. CNA 3 stated with only 2 CNAs working, CNAs would not be able to reposition residents every 2 hours, and if the resident had a urinary catheter, the resident would only be changed once in the shift. CNA 3 stated even with 4 CNAs in the subacute, it would be hard to provide showers to the residents because subacute residents had tracheostomies and G-tubes, needed total care, and were mostly nonverbal.
During an interview on 4/23/2025 at 1:16 pm with CNA 4, CNA 4 stated CNA 4 usually had 10 to 14 residents on the day shift in the subacute unit. CNA 4 stated with 10 to 14 residents, CNA 4 would not be able to provide showers to the residents unless there was a shower nurse.
During an interview on 4/23/2025 at 1:54 pm with CNA 5, CNA 5 stated CNA 5 occasionally had 12 to 14 residents on the day shift when short staffed, but normally CNA 5 would have 9 to 10 residents on the day shift. CNA 4 state call-offs caused a shortage of staff and when CNAs have 12 to14 residents then care would be affected. CNA 5 stated that when there were not enough CNAs, the shower nurse would get pulled to take an assignment and CNA 5 would not have enough time to give showers. CNA 5 stated CNA 5 would try to provide a bed bath instead of a shower but could not always provide a bed bath. CNA 5 stated in the subacute unit, CNAs were supposed to provide oral care to residents twice a shift but whenever CNA 5 had 12 to 14 residents, CNA 5 could only provide oral care once a shift.
During an interview on 4/23/2025 at 2:39 pm with Resident 8, Resident 8 stated Resident 8's shower days were on Sundays and Thursdays. Resident 8 stated for the past two weeks, Resident 8 had not had a shower or a bed bath on Thursdays. Resident 8 stated showers were not provided because CNAs would say the facility was short staffed. Resident 8 stated call lights sometimes were not answered for five hours on the night shift. Resident 8 stated sometimes CNAs on the night shift would not come around until 4 am because the facility was short staffed. Resident 8 stated Resident 8 usually turned on the call light to be changed.
During an interview on 4/23/2025 at 3:32 pm with Resident 7, Resident 7 stated when the facility was short staffed, Resident 7 would only shower once a week. Resident 7 stated that when the facility was short staffed on the night shift, it would sometimes take the staff an hour to answer the call light, and staff would only come once during the night. Resident 7 stated it had been a while since Resident 7 had two showers in a week because the facility was short staffed.
During an interview on 4/24/2025 at 10:38 am with the Director of Staff Development (DSD), the DSD stated facility staffing was not short. The DSD stated the facility scheduled enough staff on each shift for the day and go from there. The DSD stated the facility had to make sure it was meeting the State staffing hours and staff to resident ratio per day and that there were enough staff to provide care for the residents. The DSD stated the facility also scheduled a shower nurse on the day shift and on the evening shift in the subacute unit to ensure showers were being provided for the residents. The DSD stated when there was a staff call off, the facility would sometimes pull the shower nurse to cover the assignment of the person who called off. The DSD stated the main goal was for all the needs of the residents to be met and provided. The DSD stated Licensed Vocational Nurses (LVNs) in the subacute unit were also assigned two residents each shift to provide patient care to lessen the number of residents assigned to the CNAs. The DSD stated the staffing goal in the subacute was to have six (6) LVNs each shift, 5 CNAs on the day shift, 4 to 5 CNAs on the evening shift, and 3 to 4 CNAs on the night shift. The DSD stated the shower sheets for the subacute were collected by the subacute staffer (person who makes the nurse staffing schedule for the subacute) every day. The DSD stated if there was no shower sheet completed then there was no way to prove that the resident received a shower because that was how showers and bed baths were documented by the CNAs, and the licensed nurses had to sign the shower sheet.
During the same concurrent interview and record review on 4/24/2025 at 10:38 am with the DSD, the nurse staffing and assignment for the day shift (7 am to 3 pm), the evening shift (3 pm to 11 pm), and the night shift (11 pm to 7 am) from 4/7/2025 to 4/21/2025 in the subacute unit were reviewed. The review of the nurse staffing and assignment indicated that LVNs on each shift were not always assigned to two residents to provide patient care. The review of the nurse staffing and assignment indicated the following:
a. 4/7/2025 - Day shift - Census of 58. 5 CNAs were scheduled to work, but one (1) CNA called off. 4 CNAs worked with 11 residents each and there was no shower nurse (a CNA assigned to provide all resident showers scheduled for the shift) assigned. No shower was provided. The residents who were not provided with showers according to the Shower Schedule and the facility census for 4/7/2025 were Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, and Resident 26.
b. 4/7/25 - Evening shift - Census of 57. 4 CNAs worked; 3 CNAs had 11 residents, and 1 CNA had 10 residents. There was no shower nurse. The residents who were not provided with showers were Resident 5, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, and Resident 34.
c. 4/9/25 - Evening shift - Census of 59. 4 CNAs worked with 11 to 12 residents each. There was no shower nurse. No shower was provided. The residents who were not provided with showers were Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, and Resident 42.
d. 4/10/25 - Day shift - Census of 59. No CNA called off. 4 CNAs worked with 1 orientee and no shower nurse. 4 CNAs had 12 residents each. N shower was provided. The residents who were not provided with showers were Resident 17, Resident 18, Resident 29, Resident 30, Resident 38, Resident 8, and Resident 26.
e. 4/10/25 - Night shift - Census of 59. Two (2) CNAs called off and 2 CNAs worked. 1 CNA had 21 residents, and 1 CNA had 20 residents.
f. 4/11/25 - Day shift - Census of 60. 4 CNAs worked with no shower nurse. 2 CNAs had 12 residents, and 2 CNAs had 11 residents each. No call offs and no shower nurse. No shower was provided. The residents who were not provided with showers were Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, and Resident 6.
g. 4/11/25 Evening shift - Census of 60. 4 CNAs worked. 2 CNAs had 12 residents, 1 CNA had 10 residents, and 1 CNA with 11 residents. No shower nurse. No shower was provided. The residents who were not provided with showers were Resident 52, Resident 31, Resident 53, Resident 54, Resident 15, Resident 16, Resident 55, Resident 56, Resident 57, and Resident 58.
h. 4/12/25 Night shift - Census of 61. Three (3) CNAs worked with 17 residents each.
i. 4/13/25 - Day shift - Census of 61. 4 CNAs worked. 3 CNAs had 12 residents, and 1 CNA had 13 residents. The shower nurse called off and was not replaced. No shower was provided. The residents who were not provided with showers were Resident 2, Resident 7, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 38, Resident 8, and Resident 66.
j. 4/15/25 - Day shift - Census of 58. 4 CNAs with no shower nurse. CNAS had 12 residents each. No shower was provided. The residents who were not provided with showers were Resident 44, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, and Resident 6.
k. 4/17/25 - Evening shift - Census of 57. 3 CNAs worked and had 14 residents each. No shower nurse. No shower was provided. The residents who were not provided with showers were Resident 27, Resident 21, Resident 4, Resident 9, Resident 67, Resident 32, Resident 33, Resident 5, and Resident 34.
l. 4/18/25 - Day shift - Census of 57. 4 CNAs worked. 3 CNAs had 11 residents and 1 had 12 residents. No shower nurse. No shower was provided. The residents who were not provided with showers were Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, and Resident 6.
m. 4/18/25 - Evening - Census of 57. Five (5) CNAs worked with no shower nurse. 3 CNAs had 8 residents, and 2 CNAs had 9 residents. No shower was provided. The residents who were not provided with showers were Resident 52, Resident 31, Resident 53, Resident 54, Resident 15, Resident 16, Resident 55, Resident 56, Resident 57, and Resident 58.
n. 4/20/25 - Day shift - Census of 57. 3 CNAs worked with no shower nurse. 3 CNAs had 16 residents each. 2 CNAs called off and 1 CNA was a no call no show. No showers provided. The residents who were not provided with showers were Resident 2, Resident 7, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 38, Resident 8, and Resident 66.
o. 4/21/25 - Day shift - Census of 57. 4 CNAS worked. 1 CNA was a no call no show. No shower nurse was on duty because the shower nurse called off. 3 CNAs had 14 residents, and 1 CNA had 15 residents. No shower provided. The residents who were not provided with showers were Resident 17, Resident 18, Resident 19, Resident 20, Resident 29, Resident 30, Resident 22, Resident 23, Resident 24, Resident 25, and Resident 26.
During an interview with on 4/24/2025 at 3:26 pm with the Director of Nursing (DON), the DON stated no matter what, the facility needed to provide care and showers for the residents as part of accommodating the residents' needs. The DON stated not getting a shower could affect the overall well-being of the residents and not enough staffing should not be an excuse for not providing showers or care for the residents.
During a review of the facility's P&P titled, Staffing, dated 10/2017, the P&P indicated the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and facility assessment .
During a review of the facility's P&P titled, Facility Assessment, dated 10/2018, the P&P indicated, a facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations .Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources available to meet the specific needs of our residents .
During a review of the facility's FA, dated 12/10/2024, the FA indicated the staffing plan for CNAs was to provide one CNA per 8 to 9 residents on the day shift, one CNA for 10 to 13 residents on the evening shift, and one CNA for 14 to 16 residents on the night shift. The FA did not address how staff call offs would be addressed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper medication administration for six of si...
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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 proper medication administration for six of six sampled residents (Resident 5, Resident 6, Resident 26, Resident 55, Resident 56, and Resident 68) by failing to:
1. Ensure the facility followed best practices for medication preparation and administration for Resident 6 when multiple medications were crushed and mixed in one medication cup and administered via gastrostomy tube (G-tube, a feeding tube inserted directly into the stomach through the abdominal wall).
2. Ensure medications were administered at their respective scheduled times as prescribed by the ordering physicians for Resident 6, 26, 55, 56, and 68 on 4/21/2025.
3. Ensure Resident 5's medication was omitted due to lack of supply for Resident 5, without timely notification to the pharmacy or physician, potentially compromising Resident 5's treatment plan.
These deficient practices had the potential to affect Resident 6, 26, 55, 56, and 68's health, safety, and well-being by placing the residents at risk for decreased therapeutic effectiveness of the medications and potential adverse effects (unwanted effects that are related to a drug), causing increased rigidity in Resident 5's body, and potentially causing medication interactions, and G-tube occlusions (blockage) for Resident 6.
Findings:
A. During a review of Resident 5's AR, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses of respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and rheumatoid arthritis (RA- a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility).
During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had intact cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 5 required substantial/maximal assistance (helper does more than half the effort to lift or hold trunk or limbs and provides more than half the effort) for toileting, showering, personal hygiene, sit to lying, and lying to sitting on side of bed. The MDS indicated Resident 5 required partial assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs, but provides less than half the effort) to perform oral hygiene and upper body dressing, and to roll left and right. The MDS indicated Resident 5 required supervision (helper provides verbal cues and or touching as resident competes activity. Assistance may be provided throughout the activity or intermittently) for eating and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for lower body dressing, putting on/off footwear, and chair to bed transfer.
During a review of Resident 5's Order Summary, dated 1/2/2025, the Order Summary indicated to inject one dose of Adalimumab Pen-injector (medication to treat RA) once a day every two weeks on Thursday for RA.
During a review of Resident 5's Progress Notes, dated 3/13/2025, the Progress Note indicated Adalimumab Pen-injector was not available, pending delivery, sent re-fill request will be delivered tonight (3/13/2025) latest tomorrow morning (3/14/2025), and therefore not administered to Resident 5 on 3/13/2025.
During a review of Resident 5's Medication Administration Record (MAR), the MAR indicated Resident 5 received a scheduled dose of Adalimumab on 2/27/2025, and his next dose was to be administered on 3/13/2025. The MAR indicated a dose of Adalimumab was omitted (leave out or exluded) on 3/13/2025, and administered next on 3/28/2025, four weeks after his last dose on 2/27/2025.
B. During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of G-tube, type 2 diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel), hypertensive chronic kidney disease (damage to the kidney due to chronic high blood pressure [HTN- hypertension]), and atrial fibrillation (Afib- an irregular and often very rapid heart rhythm, potentially leading to blood clots in the heart).
During a review of Resident 6's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 2/20/2025, the MDS indicated Resident 6 had severely impaired cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 6 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, and tub/shower transfer.
During a review of Resident 6's Order Summary, the Order Summary indicated to administer Pantoprazole (medication to treat conditions which there is too much acid in the stomach), Alogliptin (medication to treat DM2), Amiodarone (medication to treat Afib), and Amlodipine (medication to treat hypertension) via G-tube at 9AM. The Order Summary indicated Flush tube with 20-30 milliliters (ml- unit of measurement) of water before and after medication administration.
C. During a review of Resident 26's AR, the AR indicated Resident 26 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of gastro-esophageal reflux disease (GERD , hypertension (HTN-high blood pressure), dermatitis (inflammation of the skin, characterized by redness, itching, and a rash), and seizures (a temporary burst of uncontrolled electrical activity in the brain that can cause changes in physical and mental function).
During a review of Resident 26's MDS, dated [DATE], the MDS indicated Resident 26 had severely impaired cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 26 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for oral hygiene, toileting, showering, upper and lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, and tub/shower transfer.
During a review of Resident 26's Order Summary, the Order Summary indicated to administer Amlodipine (medication to treat HTN), Metoprolol (medication to treat HTN), prednisone (medication to treat dermatitis), Omeprazole (medication to treat GERD), and Keppra (medication to treat seizures), daily at 9 AM via G-tube.
D. During a review of Resident 55's AR, the AR indicated Resident 55 was admitted to the facility on [DATE] with diagnosis of epilepsy (a neurological condition characterized by recurring seizures, which are sudden, abnormal electrical discharges in the brain).
During a review of Resident 55's MDS, dated [DATE], the MDS indicated Resident 55 had severely impaired cognition (ability to think and reason) for daily decision making and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for oral hygiene, toileting, showering, upper and lower body dressing, putting on taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, and tub/shower transfer.
During a review of Resident 55's Order Summary, the Order Summary indicated to administer Levetiracetam (medication to treat seizures/epilepsy), every 12 hours via G-tube for seizure diagnosis.
E. During a review of Resident 56's AR, the AR indicated Resident 56 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis of HTN.
During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 had severely impaired cognition (ability to think and reason) for daily decision making and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed and tub/shower transfer.
During a review of Resident 56's Order Summary, the Order Summary indicated to administer Metoprolol (medication to treat hypertension), daily at 9 AM via G-tube.
F. During a review of Resident 68's AR, the AR indicated Resident 68 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of HTN, epilepsy, GERD, and anxiety (persistent feeling of dread or panic that can interfere with daily life).
During a review of Resident 68's MDS dated [DATE], the MDS indicated Resident 68 had severely impaired cognition (ability to think and reason) for daily decision making and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for oral hygiene, toileting, showering, upper and lower body dressing, putting on taking off footwear, personal hygiene, roll left and right and tub/shower transfer.
During a review of Resident 68's Order Summary, the Order Summary indicated to administer Lacosamide (medication to treat epilepsy), Levetiracetam, Hydroxyzine (medication to treat anxiety), Amlodipine (medication to treat HTN), and Omeprazole (medication to treat GERD), daily at 9 AM via G-tube.
During a concurrent observation and interview on 4/21/2025 at 10:27 AM with Licensed Vocational Nurse 7 (LVN 7), LVN 7 was observed passing medications to Resident 6 in Resident 6's room. LVN 7 stated LVN 7 was late in administering Resident 6's medications because three licensed nurses called off, therefore increasing her patient workload to pass medications, and was also going to be late giving medications to Resident 26, 55, 56, and 68. LVN 7 stated facility protocol to administer medications was one hour before and one hour after the prescribed time which was 9 AM. LVN 7 was observed placing the following medications into one cup and mixing them together with water: Alogliptin, Amiodarone, amlodipine, and Pantoprazole, then administer them to Resident 6 via G-tube which was not infusing the medication via gravity. LVN 7 stated LVN 7 had not checked for G-tube placement prior to administration of medications, and LVN 7 was aware that best practice was to administer each medication separately, flushing with water after each medication to prevent occlusion of the g-tube. LVN 7 stated LVN 7 had not utilized the best nursing practice because LVN 7 felt pressed for time since LVN 7 had to administer medications to four more residents (Residents 26, 55, 56 and 68) and LVN 7 was just trying to move as fast as possible.
During an interview on 4/21/2025 at 10:34 AM with Resident 5, Resident 5 stated Resident 5 was concerned with Resident 5's health status because Resident 5 was supposed to get Resident 5's injection to manage Resident 5's arthritis every two weeks, but sometimes the nurses told him the medication was not available in the facility. Resident 5 stated Resident 5 had been taking this medication for nearly two years, and Resident 5 is constantly reminding the staff about his injection so that they can order it ahead of time. Resident 5 stated he felt the nurses would get mad when Resident 5 persisted in reminding the licensed nurses. Resident 5 stated Resident 5 reminded staff because when Resident 5 did not get Resident 5's medication on time every two weeks, Resident 5 felt nervous, and Resident 5's shoulders, knees, hips, and bilateral arms would hurt. Resident 5 stated Resident 5 received medications to treat the pain, but the injection helped mostly with controlling the rigidity in Resident 5's body. Resident 5 stated when a dose was omitted and received the next dose at the next scheduled time, the medication was not as effective in controlling the rigidity in Resident 5's body.
During an interview on 4/21/2025 at 11:19 AM with the Director of Staff Development (DSD), the DSD stated the facility was responsible for having enough staff to give medication on time. The DSD stated that not giving medications to residents on time was unacceptable. The DSD stated licensed nurses must check for g-tube placement, if residual was more than 100 ml, the nurse had to stop the feeding. The DSD stated medications had be administered in different cups and flushed with 15-30 ml of water before and after each medication administration. The DSD stated it was unacceptable to give all the medications together because some medications increase the risk of drug to drug interactions, tube blockage, and alter medication absorption.
During an interview on 4/21/2025 at 1:22 PM with Registered Nurse Supervisor (RNS) 2, RNS 2 stated to ensure medications such as Adalimumab Pen-injector are available in the facility, the nursing staff must order the medication that was in the short supply room as soon as the nurses administered the medication. RNS 2 stated RNS 2 was aware the medication was order only once every two weeks because the medication was very expensive. RNS 2 stated that if a nurse gave the last injection, the nurse should notify the pharmacy the same day so that it was ready to be administered again in two weeks or whenever the next dose was due. RNS 2 stated nurses must endorse this information to the next shift so that everyone was aware and responsible for ensuring medications for residents were available in the facility to prevent omitting a dose of medication because it can have adverse effects for residents' well-being.
During an interview on 4/21/2025 at 1:32 PM with the Director of Nursing (DON), the DON stated the charge nurse, or any licensed nurse should order medications ahead of time, consistently, so the residents have their medications available in the facility. The DON stated failure to ensure medications are available can result in unmanageable pain, and in this case manifest flare ups for Resident 5 who had RA. The DON stated if there was only 2 or 3 injections left of the injection, nurses should order immediately to ensure proper and timely delivery of the medication. The DON stated it was important for licensed nurses to administer medications on time, one hour before or one hour after medication was due to ensure therapeutic effectiveness, particularly for time-sensitive medications such as seizure medications, pain medications, antibiotics (medications to treat infection), and hypertension medications. The DON stated checking for G-tube placement prior to administering medication was important to ensure the tube had not become dislodged, which could result in aspiration (accidental breathing in of food or fluid into the lungs, potentially causing pneumonia or other lung problems) or ineffective delivery of medications.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, indicated staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time, unless otherwise specified.
During a review of the facility's P&P titled, Pharmaceutical Services, dated November 2020, indicated Medications shall be ordered from Alliance Pharmacy. Refills of medications should be called to the pharmacy 3 to 4 days in advance of need to assure an adequate supply is on hand.
During a review of the facility's P&P titled, Administering Medications Through an Enteral Tube [soft, flexible plastic tubes through which liquid nutrition travels], dated November 2018, indicated verify placement of feeding tube, administer each medication separately and flush between medications.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep the facility clean for four of four rooms (Rooms...
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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 keep the facility clean for four of four rooms (Rooms 421, 416, 222 and 223).
1. There were dried reddish-brown stains on the privacy curtain next to the bed by the window in room [ROOM NUMBER]. The privacy curtain separated the two beds in room [ROOM NUMBER].
2. The baseboards in room [ROOM NUMBER] were dirty.
3. There were unpainted white patches on the walls in room [ROOM NUMBER].
4. There was a brownish gray stain on the ceiling and on the top of the wall by the air vent in room [ROOM NUMBER].
5. There were holes in the wall with chipped paint behind the headboard of the bed by the window in room [ROOM NUMBER].
6. The baseboards in room [ROOM NUMBER] were dirty.
7. The linoleum flooring in the restroom in room [ROOM NUMBER] was cracked and peeling off the wall.
8. The sink in the restroom in room [ROOM NUMBER] was chipped and the faucet was corroded.
9. The window tint on the sliding door in room [ROOM NUMBER] was peeling off.
10. There were brown stains on the ceiling above both beds in room [ROOM NUMBER].
11. There were brown stains on the ceiling in the hallway in front of room [ROOM NUMBER] and in front of the storage room by room [ROOM NUMBER].
12. The Maintenance Department's Checklist did not indicate which resident rooms were checked on each day of the month and what items were checked in each room.
These failures resulted in unclean environment for Residents 11, 12, other residents, staff and visitors.
Findings:
During a concurrent observation and interview on 4/22/2025 at 3:41 pm inside room [ROOM NUMBER], Resident 11 stated the housekeeper deep cleaned room [ROOM NUMBER] on 4/21/25, but the baseboards in room [ROOM NUMBER] were still dirty. Resident 11 stated there was dried blood on the privacy curtain by Resident 11's bed which had been there since Resident 11 moved into room [ROOM NUMBER] about two months ago. Resident 11 told a staff member (unable to identify) to change the privacy curtain when Resident 11 moved into room [ROOM NUMBER], but the curtain still had not been changed. The privacy curtain which separated the two beds in room [ROOM NUMBER] was observed to have dried reddish-brown stains on the side next to Resident 11's bed. Resident 11 stated there were multiple white patches on the walls of room [ROOM NUMBER] and a grayish discoloration on the ceiling by the air vent in room [ROOM NUMBER]. The baseboards in room [ROOM NUMBER] were observed to be dirty and there were multiple unpainted white patches on the wall in room [ROOM NUMBER]. There was also a brownish gray stain on the ceiling and on the top of the wall by the air vent in room [ROOM NUMBER].
During a concurrent observation and interview on 4/22/2025 at 4:01 pm inside room [ROOM NUMBER], Resident 12 showed the surveyor the wall behind the headboard of Resident 12's bed. There were holes in the wall with chipped paint behind the headboard of Resident 12's bed. Resident 12 stated the holes in the wall with chipped paint had been there since Resident 12 moved into room [ROOM NUMBER]. Resident 12 also pointed to the sliding door in room [ROOM NUMBER] and the window tint on the sliding door was observed to be peeling off. The baseboards in room [ROOM NUMBER] were also dirty. Resident 12 stated the tile flooring was cracked, and the sink is corroded in the restroom in room [ROOM NUMBER]. The linoleum flooring in the restroom in room [ROOM NUMBER] was observed to be cracked and peeling off the wall, and the sink in the restroom was chipped and the faucet was corroded.
During a concurrent observation and interview on 4/23/2025 at 1:16 pm with Certified Nursing Assistant (CNA) 4, CNA 4 showed the surveyor the brown stains on the ceiling above both beds in room [ROOM NUMBER]. CNA 4 did not know how long the brown stains had been on the ceiling in room [ROOM NUMBER]. There were brown stains observed on the ceiling in the hallway in front of room [ROOM NUMBER] and in front of the storage room by room [ROOM NUMBER].
During a concurrent observation and interview on 4/23/2025 at 3:56 pm with Maintenance Assistant (MA) 1, MA 1 stated the facility had some water stains on the ceiling from the leaks on the roof which were now fixed. MA 1 did not remember when the roof was fixed. MA 1 stated the Maintenance Department did not make a note of which rooms had water stains on the ceiling because staff (general) usually told the Maintenance Department which rooms had water stains. MA 1 stated the major leak was in room [ROOM NUMBER] and the ceiling in room [ROOM NUMBER] was fixed. The Maintenance Department staff did not fix the ceilings in all the other rooms even though they knew about it because the roof had been leaking on and off. MA 1 stated, Now that the roof is fixed then we (Maintenance Department) will change them (ceiling) out. MA1 made a note of the brown stains on the ceiling in the hallway in front of room [ROOM NUMBER] and in front of the storage by room [ROOM NUMBER]. MA 1 checked room [ROOM NUMBER] and stated the brown stains on the ceiling above the bed next to the window was a water stain, but the stain on the ceiling above the bed close to the door was probably from a feeding formula splashing onto the ceiling. MA 1 stated chipped paint in resident rooms had to be written down by staff (general) in the Maintenance Log (ML) kept in each nurses' station. MA 1 stated when things were broken or needed work in the resident rooms, the Maintenance Department would not know about them unless they were written in the ML and/or unless the Maintenance Department sees them. MA 1 stated the Maintenance Department checks every call light in each resident rooms in the facility every month. MA 1 went inside room [ROOM NUMBER], saw the white patches on the walls, and stated, We patched up the walls and forgot to come back to paint. MA 1 went inside room [ROOM NUMBER] and saw the holes in the wall with chipped paint behind the headboard of Resident 12's bed. MA 1 stated, I did not see that (holes and chipped paint on the wall in room [ROOM NUMBER]) when I checked the call light, it is new. Resident 12, who was present in room [ROOM NUMBER], stated the holes in the wall along with the chipped paint were already there when Resident 12 moved into the room and were not new. MA 1 stated, There's only three of us, but did not explain further. MA 1 went inside the restroom in room [ROOM NUMBER] and made a note of the cracked and peeling linoleum tile, the chipped sink, and the corroded faucet. MA 1 looked at the peeling window tint on the sliding door in room [ROOM NUMBER] and stated the window tint was put on by an outside company so MA 1 would have to contact them.
During an interview on 4/23/2025 at 4:17 pm with the Director of Housekeeping, Laundry, and Food Services (DHLF), the DHLF stated privacy curtains in resident rooms were changed as needed and during deep cleaning day of the room. The DHLF stated room [ROOM NUMBER] was deep cleaned on 4/21/2025, but the privacy curtain was not changed because there was no male staff who could take down the privacy curtain on that day. The DHLF stated if there was blood or a stain on the privacy curtain, it was important that the curtain be changed right away because of infection control issues and to make it look good for the residents. The DHLF stated the privacy curtain for room [ROOM NUMBER] was changed today, 4/23/2025.
During an interview on 4/24/2025 at 10:38 am with the Director of Staff Development (DSD), the DSD stated any staff who noticed any repair needed should place it in the Maintenance Log in the nurses' station right away so the Maintenance Department would become aware of things which needed to be repaired. Any dried blood or stain on the privacy curtain should be reported by nursing to housekeeping and/or laundry right away so they can remove the privacy curtain and clean it.
During an interview on 4/24/2025 at 3:26 pm with the Director of Nursing (DON), the DON stated privacy curtains which were soiled and stained with blood must be replaced once identified. The DON stated feces and/or blood could be contaminated and affect the health of residents and staff. The DON stated every resident has a right to live in a homelike environment, and cleanliness and sanitation for the health of the residents.
During an interview on 4/24/2025 at 4:14 pm with the Administrator (ADM), the ADM stated the facility roof leaked during the rainy season and was repaired in January or February of 2025. The ADM was informed of all the environmental issues discussed with MA 1, the dirty baseboards in the resident rooms, and the dried reddish-brown stain on the privacy curtain in a resident's room. The ADM stated the ADM expected the Maintenance Department to make routine rounds in resident rooms on a weekly basis and to follow a log. Expectation was for the Maintenance Department to go back and fix anything they find which needed fixing during their routine rounds in resident rooms. The ADM stated nurses should write down anything they notice which needed repair in the Maintenance Book or Log (ML) and the first thing the Maintenance Department should do in the morning was to go over the ML and prioritize the items written in the ML. The April 2025 Maintenance Department's Checklist was reviewed with the ADM. The Checklist did not indicate which resident rooms were checked on each day of the month and what items were checked in each room. The ADM stated, They (Maintenance Department) probably need to do a more thorough inspection when doing facility rounds and might have missed it (environmental issues discussed).
During a review of the Deep Clean Check off List, dated 4/21/2025, the Deep Clean Check off List (DCL) indicated a housekeeping staff completed the deep cleaning of room [ROOM NUMBER] on 4/21/2025. The DCL indicated the roof, the walls, the vents, and the trim (baseboards) inside room [ROOM NUMBER] was cleaned.
During a review of the facility policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated 5/2017, the P&P indicated the facility would provide residents with a safe, clean, sanitary, comfortable, and orderly environment.
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
Smoking Policies
(Tag F0926)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Smoking by Residents, for one of three sampled residents (Resident...
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Based on observation, interview, and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Smoking by Residents, for one of three sampled residents (Resident 1) by failing to:
1. Ensure Resident 1 was supervised while smoking in the smoking patio.
2. Ensure Resident 1 ' s smoking materials were stored in a locked box or drawer.
These deficient practices had the potential to place Resident 1 and other residents ' safety at risk.
Findings:
During an observation on 4/3/2025 at 2:56 pm of the smoking patio, there were three residents sitting up in a wheelchair in the smoking patio. Resident 1 was observed smoking a cigarette. There was no staff observed supervising Resident 1 while smoking.
During an observation on 4/3/2025 at 5:09 pm of Resident 1 ' s room, there was a lighter observed on Resident 1 ' s bed.
During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 9/5/2024 and recently admitted Resident 1 on 2/23/2025 with diagnoses that included encephalopathy (damage or disease that affects the brain), respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body), and asthma (a long-term condition that affects the airways in the lungs).
During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 3/7/2025, the MDS indicated Resident 1 was understood by others and had the ability to understand others. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering/bathing self, and lower body dressing.
During a review of Resident 1 ' s Smoking and Safety (SAS), dated 3/12/2025, the SAS indicated Resident 1 followed the policy ' s location and time of smoking.
During a review of Resident 1 ' s Interdisciplinary Team Conference Record (IDT), dated 3/12/2025, the IDT indicated the IDT was conducted secondary to education regarding smoking policy and need for supervision. The IDT indicated the purpose of the IDT was to enhance resident/responsible party awareness of the facility smoking policy and resident ' s responsibility related to smoking that included: smoking under supervision, adherence to facility policy on smoking, including scheduled smoking times, and possibility of limiting the accessibility of matches and lighters.
During a review of the facility ' s Smoking Schedule (SS), the SS indicated to please follow the designated smoking times, which were from 9 am to 9:30 am, 11 am to 11:30 am, 1:30 pm to 2 pm, 3:30 pm to 4 pm, and 6 pm to 6:30 pm, with activities staff as designee (a person who has been formally chosen or appointed to perform a specific duty or role).
During an interview on 4/3/2025 at 3:54 pm, with the Administrator (ADM), the ADM stated activities staff were assigned to supervise residents who smoked in the smoking patio. The ADM stated even if a resident was alert and oriented, they should still be supervised during smoking.
During an interview on 4/3/2025 at 5:19 pm, with the Activities Director (AD), the AD stated the AD did not know how Resident 1 got a lighter. The AD stated Resident 1 used to have the smoking materials locked up. The AD stated Resident 1 having a lighter could hurt or harm Resident 1 or other residents.
During a telephone interview on 4/7/2025 at 3:47 pm, with the Director of Nursing (DON), the DON stated regardless of if a resident was alert or not, the resident still needed to be supervised while smoking. The DON stated smoking materials needed to be locked for safety reasons because another resident could access the smoking materials.
During a review of the facility ' s P&P titled, Smoking by Residents, dated September 2018, the P&P indicated as identified by the Safe Smoking Assessment, residents who require assistance and/or monitoring for smoking safety are not allowed to smoke unaccompanied/unsupervised. The IDT will develop an individualized plan for safe storage and use of smoking materials, assistance and required supervision, if necessary. This information will be documented on the resident ' s safe smoking assessment, in the resident ' s care plan, and discussed with resident ' s/responsible party during care conference meetings. Residents will not be permitted to keep smoking materials in their possession, unless the IDT determines that they can manage them safely. If the smoking materials are to be kept in the resident ' s possession, they must be stored in a locked box or drawer.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the facility ' s policy and procedure (P&P) ti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Maintenance Service, by failing to ensure floor tiles in two of six stations (Station 4 and Station 6) of the facility were free of holes and cracks.
This deficient practice had the potential to place the safety of residents, staff, and visitors at risk.
Findings:
During an observation on 4/3/2025 at 1:50 pm, with the Maintenance Staff (MS), the following were observed:
a. The floor at the doorway of room [ROOM NUMBER] in Station 4 had a hole which measured two by 24 inches.
b. There was a hole around the drain in a hallway of Station 4 with a measurement of four inches.
c. There were cracks on the floor tiles in the hallway in front of the facility ' s beauty salon on Station 6.
d. The floor at the doorway of room [ROOM NUMBER] in Station 6 had a hole with a measurement of three by eight inches.
During an interview on 4/3/2025 at 4:06 pm, with the Administrator (ADM), the ADM stated the holes on the floor indicated the
environment was not homelike. The ADM stated the holes on the floor could cause staff or residents to have a fall.
During a review of the facility ' s P&P titled, Maintenance Service, revised in December 2009, the P&P indicated Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are limited to maintaining the building in good repair and free from hazards.
Mar 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure the ordered tab alarm (device used to notify staff when residents attempted to transfer unassisted by staff) was attac...
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Based on observation, interview, and record review, the facility failed to ensure the ordered tab alarm (device used to notify staff when residents attempted to transfer unassisted by staff) was attached to one of three sampled residents (Resident 8) who was at risk of falls.
This failure resulted in Resident 8 falling to the floor on 3/12/2025 while in the care of the facility. The failure had the potential for Resident 8 to be injured due to the fall.
Findings:
During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on 3/11/2025 with diagnoses including hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems).
During a review of Resident 8's Fall Risk Evaluation, dated 3/12/2025, the Fall Risk Evaluation indicated score 10 or higher was a high risk of falls. The Fall Risk Evaluation, indicated to initiate fall risk precautions.
During a review of Resident 8 ' s Post Fall Evaluation, dated 3/12/2025, the Post Fall Evaluation indicated Resident 8's pre-fall risk score was 15. The Post Fall Evaluation indicated Resident 8 fell on 3/12/2025. The Post Fall Evaluation indicated Resident 8 ' s personal alarm did not sound while Resident 8 was found on the floor.
During a review of Resident 8's History and Physical (H&P), dated 3/13/2025, the H&P indicated Resident 8 did not have the capacity to understand and make decisions.
During a review of Resident 8 ' s Order Summary Report, dated 3/13/2025, the Order Summary Report indicated Resident 8 had a physician order dated 3/11/2025, .tab alarm while in bed to alert the staff of unassisted transfer.
During a telephone interview on 3/13/2025 at 1:00 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated CNA 1 was assigned to care for Resident 8 on 3/12/2025. CNA 1 stated Resident 8 fell from his bed on 3/12/2025. CNA 1 stated CNA 1 was aware Resident 8 was at risk for falls. CNA 1 stated Resident 8 had a tab alarm the facility staff applied to Resident 8 while Resident 8 was lying in bed. CNA 1 stated CNA 2 notified CNA 1 that Resident 8 had fallen. CNA 1 stated when CNA 1 arrived at Resident 8 ' s room, Resident 8 ' s tab alarm was not sounding.
During a telephone interview on 3/13/2025 at 1:24 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LVN 1 was assigned to care for Resident 8 on 3/12/2025. LVN 1 stated Resident 8 moved a lot, and that Resident 8 did not want to lay in bed. LVN 1 stated Resident 8 needed a tab alarm to notify staff when Resident 8 tried to get out of bed. LVN 1 stated Resident 8 ' s tab alarm sounded two times during the shift and when LVN 1 responded to the alarm, Resident 8 was trying to get out of bed without assistance from staff.
During an interview on 3/13/2025 at 1:40 p.m. with CNA 2, CNA 2 stated CNA 2 found resident 8 on the floor next to Resident 8 ' s bed on 3/12/2025 at around 12:30 p.m. CNA 2 stated Resident 8 was lying face down on the floor.
During a concurrent observation and interview on 3/13/2025 at 1:50 p.m. with CNA 2 in Resident 8 ' s room, Resident 8 ' s tab alarm was observed. The tab alarm consisted of a rectangular box with a cord connected to the box by a magnet. When the magnet was pulled off the box, an alarm sounded. At the other end of the cord was a metal clip that was clipped to Resident 8 ' s hospital gown. CNA 2 stated Resident 8 ' s tab alarm was not sounding. CNA 2 stated Resident 8 ' s tab alarm was not clipped to Resident 8.
During a concurrent observation and interview on 3/13/2025 at 2:38 p.m. with the Maintenance Assistance (MA), a tab alarm was observed. The MA stated the tab alarm was a device used to alert staff when residents (in general) were attempting to get out of bed unassisted. The MA stated the box was to be clipped to the resident ' s (in general) bed and the cord was to be clipped to the resident ' s (in general) clothing. The MA stated the tab alarm would sound when the cord was pulled from the box. The MA stated when staff heard the alarm, the staff should think a resident (in general) was trying to get out of bed.
During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised March 2018, the P&P indicated, Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.
During a review of the facility ' s manufacturers manual, titled Basic Series Magnet Alarm Monitor, undated, the manual indicated, .Place the alarm box on the desired monitoring surface (bed or chair or floor) and make sure that the magnet is sturdily and place. Attach the alligator clip to the patient's shirt being careful not to catch the patient's skin .Warning: the effectiveness of monitors and sensor pad systems depends on proper equipment installation and operation. Always test the system prior to use .
Feb 2025
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to protect a resident's right to remain free from verbal (the use of oral, written or gestured communication or sounds that willfully includes...
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Based on interview and record review, the facility failed to protect a resident's right to remain free from verbal (the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents) and physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) for one of two sampled residents (Resident 2), when Resident 3 physically and verbally abused Resident 2 on 2/10/2025.
This failure had the potential to result in bodily injury to Resident 2 and/or Resident 2 to feel afraid and not safe while under the care of the facility.
Findings:
A1. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 9/5/2024 with diagnoses including encephalopathy (brain disease that alters brain function or structure), respiratory failure (when the lungs can't get enough oxygen into the blood), and pneumonia (infection that inflames air sacs in one or both lungs).
During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 12/9/2024, the MDS indicated Resident 2 had no impairments in cognitive skills (ability to make daily decisions). The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing and toileting and personal hygiene.
During a review of Resident 2's Progress Notes (PN), dated 2/13/2024, the PN indicated on 2/10/2025 timed 3:48 p.m., (Resident 2) was backing up in the hallway when (Resident 3) stood up and swung from behind and hit his (Resident 2) shoulder. The PN indicated Resident 2 had an abrasion on Resident 2's left cheek due to the physical altercation with Resident 3.
A2. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 2/14/2023 and readmitted Resident 3 on 5/16/2024 with diagnoses including Huntington's disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).
During a review of Resident 3's MDS, dated 2/10/2025, the MDS indicated Resident 3 was moderately impaired in cognitive skills. The MDS indicated Resident 3 required partial/moderate (helper does less than half the effort) assistance from staff for bathing, toileting and personal hygiene, and lower body dressing.
During a review of Resident 3's PN, dated 2/13/2024, the PN indicated on 2/10/2025 timed 12:26 p.m., (Resident 2) was backing up his wheelchair not aware that he (Resident 3) was behind him (Resident 2). Resident (Resident 3) pushed (Resident 2's) wheelchair, stood up and started yelling at the resident (Resident 2) swung from behind and hit (Resident 2's) shoulder sustained small abrasion on left cheek upon body assessment.
A3. During a review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 7/6/2023 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), alcoholic cirrhosis of the liver (a chronic liver disease caused by excessive and prolonged alcohol consumption) with ascites (abdominal swelling caused by accumulation of fluid), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
During a review of Resident 5's MDS, dated 1/2/2025, the MDS indicated Resident 1 had no impairments in cognitive skills. The MDS indicated Resident 5 required partial/moderate (helper does less than half the effort) from staff for bathing. The MDS indicated Resident 5 required setup or clean-up assistance from staff for eating and toileting, oral, and personal hygiene.
During an interview on 2/20/2025 at 12:25 p.m. with Resident 5, Resident 5 stated Resident 3 had a history of yelling at other residents. Resident 5 stated Resident 5 witnessed Resident 3 yelling at residents (in general), I'll kill you; I'll rip your f-ing head off. Resident 5 stated Resident 5 also witnessed Resident 3 say I'll kill you; I'll rip your f-ing head off, to Resident 2 by the smoking patio last week. Resident 5 stated Resident 3 slapped Resident 2 on the back of Resident 2's head.
A4. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 6/15/2012 and readmitted Resident 6 on 2/15/2024 with diagnoses including type 2 diabetes mellitus , hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood).
During a review of Resident 6's MDS, dated 2/4/2025, the MDS indicated Resident 6 had no impairments in cognitive skills . The MDS indicated Resident 6 required partial/moderate (helper does less than half the effort) from staff for bathing, dressing, and toileting and personal hygiene.
During an interview on 2/20/2025 at 11:37 a.m. with Resident 6, Resident 6 stated Resident 6 witnessed Resident 3 yelling at Resident 2 and shoving Resident 2 in Resident 2's back. Resident 6 stated Resident 2 was wheeling Resident 2's wheelchair backwards from the smoking patio into the facility and Resident 3 was in the way. Resident 6 stated Resident 3 shouted at Resident 2, F### you, I'll kill you. Resident 6 stated Resident 3 went behind Resident 2 and shoved Resident 2 in Resident 2's back.
During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention Program, revised December 2016, the P&P indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 one sampled resident (Resident 4) received Physical Therapy (PT, specialized rehabilitative service that helps you improve ho...
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Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 4) received Physical Therapy (PT, specialized rehabilitative service that helps you improve how your body performs physical movements) and Occupational Therapy (OT, specialized rehabilitative service that helps you improve your ability to perform daily tasks) as indicated in Resident 4's untitled care plan, dated 2/25/2025.
This failure had the potential for Resident 4 to not attain, maintain or restore his highest practicable level of physical, mental, functional and psycho-social well-being.
(Cross Reference F693 and F825)
Findings:
During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 8/31/2024 diagnoses including traumatic subarachnoid hemorrhage (SAH, a type of bleeding in the brain), acute respiratory failure (when the lungs can't get enough oxygen into the blood), and dysphagia (difficulty swallowing foods or liquids).
During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 12/20/2024, the MDS indicated Resident 4 was severely impaired (never/rarely made decisions) impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident was dependent (helper does all the effort) on staff for toileting, oral, and personal hygiene, dressing, and bathing.
During a review of Resident 4's untitled care plan, initiated on 2/25/2025 indicated Resident 4 has an activities of daily living (ADL, a term used to describe the skills required to independently care for oneself), self-care performance deficit related to limited mobility limited range of motion (ROM). The goal was for Resident 4 to maintain current level of function through the revie date of 3/20/2025. The interventions were for Resident 4 to receive PT and OT evaluation and treatment and encourage Resident 4 to participate (in PT and OT) to the fullest extent possible with each interaction.
During a concurrent interview and record review on 2/25/2025, at 11:27 a.m. with the Director of Rehabilitation (DOR), Resident 4's Physical Therapy (PT) Initial Evaluation (PT Eval), dated 11/15/2025 and Occupational Therapy (OT) Initial Evaluation (OT Eval), dated 11/15/2025 were reviewed. The OT Eval indicated Resident 4's rehab potential was good. The OT eval indicated Resident 4 had a treatment plan to be conducted six times a week for four weeks with OT. The OT Eval indicated Resident 4 only receive one session of OT and did not receive four weeks of treatment from. The PT Eval indicated had a treatment plan to be conducted six times a week for 4 weeks with PT. The PT Eval indicated Resident 4 only receive one session of PT and did not receive four weeks of treatment from PT. The DOR confirmed PT and PT both indicated Resident 4 would benefit from PT and OT. The DON stated Resident 4 did not receive the PT and OT treatment plan because the facility was waiting for Resident 4's insurance to authorize the PT and OT services. The DOR stated Resident 4's insurance did not approve Resident 4 to receive PT and OT. The DOR stated Resident 4 did not currently receive PT and OT.
During a concurrent interview and record review on 2/25/2025, at 12:40 p.m. with the DOR, Resident 4's care plan titled Resident requires skilled physical therapy ., dated 10/11/2025 was reviewed. The care plan indicated Resident 4 required PT due to decreased strength and endurance. The care plan indicated a goal was for Resident 4 to have an increase in strength to both legs. The care plan indicated Resident 4 would receive therapeutic activities. The DOR stated the care plan was appropriate for Resident 4. The DOR stated Resident 4 still needed PT.
During an interview on 2/25/2025 at 1:05 p.m. with the Director of Nursing (DON), the DON stated a resident's (in general) care plan was created to address all the needs of the resident. The DON stated the care plan contained interventions needed to address the resident's needs while at the facility. The DON stated if the care plan indicated the resident needed PT and/or OT then the resident should receive PT and/or OT.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure proper care and treatment for gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition di...
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Based on observation, interview, and record review, the facility failed to ensure proper care and treatment for gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) was provided for two of three sampled residents (Resident 4 and Resident 8) when:
a. Resident 4's head of bed (HOB) was not elevated to an angle of 30-45 degrees while on G-tube feeding.
b. Licensed Vocational Nurse (LVN) 2, who was administering five medications to Resident 8 via Resident 8's G-tube, failed to flush the G-tube with water between administering the second, third, and fourth medications.
These failures had the potential to put Resident 4 at risk for aspiration pneumonia (a form of pneumonia that occurs when food particles/foreign materials enter the lungs) and/or choking and had the potential for Resident 8's G-tube to become clogged and/or medications not to be administered correctly.
(Cross Reference F656 and F825)
Findings:
a. During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 8/31/2024 diagnoses including traumatic subarachnoid hemorrhage (SAH, a type of bleeding in the brain), acute respiratory failure (when the lungs can't get enough oxygen into the blood), and dysphagia (difficulty swallowing foods or liquids).
During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 12/20/2024, the MDS indicated Resident 4 was severely impaired (never/rarely made decisions) impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident was dependent (helper does all the effort) on staff for toileting, oral, and personal hygiene, dressing, and bathing.
During a concurrent observation and interview on 2/20/2025 at 2:15 p.m. with Licensed Vocational Nurse (LVN) 1in Resident 4's room, Resident 4 was lying in bed with Resident 4's enteral feeding (a method of providing nutrition directly into the gastrointestinal [GI] tract through a tube) running via Resident 4's G-tube. The HOB was raised slightly. LVN 1 stated the HOB needed to be raised to 30 - 40 degrees. LVN 1 stated LVN 1 did not know how high the HOB was raised but was sure it was not raised high enough. LVN 1 stated there were no marks on the bedframe to determine the degree of the HOB.
During an interview on 2/24/2025 at 3:15 p.m. with the Director of Nursing (DON), the DON stated the HOB must be raised to 35-45 degrees whenever residents (in general) where receiving enteral feeding.
During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, revised November 2018, the P&P indicated, Elevate the head of the bed (HOB) at least 30° during tube feeding and at least 1 hour after feeding.
b. During a review of Resident 8's AR, the AR indicated the facility admitted Resident 8 on 7/12/2019 and readmitted Resident 8 on 6/17/2024 with diagnoses including hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), acute and chronic respiratory failure, and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar).
During a review of Resident 8's MDS, dated 11/15/2024, the MDS indicated Resident 8 was severely impaired in cognitive skills. The MDS indicated Resident was dependent (helper does all the effort) on staff for toileting, oral, and personal hygiene, dressing, and bathing.
During a review of Resident 8's Order Summary Report, dated 2/25/2025, the Order Summary Report indicated Resident 8 had active orders from the physician for medications, including:
1. Clonazepam (medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain]) Tab 2 milligram (mg, a unit of measurement) Give 1 tablet via G-Tube two times a day for seizure.
2. Docusate Sodium (medication used to treat constipation) Oral Tablet 100 mg Give 2 tablet via G-Tube two times a day for constipation.
3. Lisinopril (medication used to treat hypertension (HTN, high blood pressure) Tab 20 mg Give 1 tablet via G-Tube one time a day for HTN.
4. Metoprolol Tartrate (medication used to treat HTN) Tab 50 mg Give 1 tablet via G-Tube two times a day
5. Levetiracetam Oral Solution (medication used to treat seizures) 100 mg/ml Give 7.5 ml via G-tube two times a day for seizures
During a medication administration observation on 2/25/2025 at 8:48 a.m. with LVN 2, LVN 2 administered five medications to Resident 8 via Resident 8's G-tube. The five medications were Clonazepam, Docusate Sodium, Lisinopril, Metoprolol Tartrate, and Levetiracetam. LVN 2 administered the first medication and then flushed the G-tube with water before administering the second medication. LVN 2 failed to flush the G-tube with water between LVN 2 administering the second, third, the fourth medication. LVN 2 administered the fourth medication and flushed the G-tube with water before giving the fifth medication.
During an interview on 2/25/2025 with the DON, the DON stated medications given via G-tube need to be flushed with water between medications to help with medication absorption and to keep the G-tube from clogging.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications through an Enteral Tube, revised November 2018, the P&P indicated, If administering more than one medication, flush with 15 mL warm purified water (or prescribed amount) between medications.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 4) received Physical Therapy (PT, specialized rehabilitative service that helps you improve ho...
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Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 4) received Physical Therapy (PT, specialized rehabilitative service that helps you improve how your body performs physical movements) and Occupational Therapy (OT, specialized rehabilitative service that helps you improve your ability to perform daily tasks) as indicated in the Resident 4's plan of care.
This failure resulted in Resident 4 did not receive PT and OT services as indicated in Resident 4's care plan and had the potential for Resident 4 to not attain, maintain or restore Resident 4's highest practicable level of physical, mental, functional and psycho-social well-being.
(Cross Reference F656 and F693)
Findings:
During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 8/31/2024 diagnoses including traumatic subarachnoid hemorrhage (SAH, a type of bleeding in the brain), acute respiratory failure (when the lungs can't get enough oxygen into the blood), and dysphagia (difficulty swallowing foods or liquids).
During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 12/20/2024, the MDS indicated Resident 4 was severely impaired (never/rarely made decisions) impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident was dependent (helper does all the effort) on staff for toileting, oral, and personal hygiene, dressing, and bathing.
During a review of Resident 4's physician orders, the physician orders indicated the following therapy orders for Resident 4:
Occupational Therapy Evaluate and Treat as Indicated, dated 11/14/2024
Physical Therapy Evaluate and Treat as Indicated, dated 11/14/2024
OT eval completed awaiting authorization. Once authorized OT clarification of order for skilled services QD (every day) 6 times a week for 4 weeks for tx (treatment) ., dated 11/15/2024
PT clarification order for Skilled Physical Therapy Services QD . X 4 wks (weeks) (awaiting auth from insurance .), dated 11/15/2024.
During a concurrent interview and record review on 2/25/2025, at 11:27 a.m. with the Director of Rehabilitation (DOR), Resident 4's Physical Therapy (PT) Initial Evaluation (PT Eval), dated 11/15/2025 and Occupational Therapy (OT) Initial Evaluation (OT Eval), dated 11/15/2025 were reviewed. The OT Eval indicated Resident 4's rehab potential was good. The OT eval indicated Resident 4 had a treatment plan to be conducted six times a week for four weeks with OT. The OT Eval indicated Resident 4 only receive one session of OT and did not receive four weeks of treatment from. The PT Eval indicated had a treatment plan to be conducted six times a week for 4 weeks with PT. The PT Eval indicated Resident 4 only receive one session of PT and did not receive four weeks of treatment from PT. The DOR confirmed PT and PT both indicated Resident 4 would benefit from PT and OT. The DON stated Resident 4 did not receive the PT and OT treatment plan because the facility was waiting for Resident 4's insurance to authorize the PT and OT services. The DOR stated Resident 4's insurance did not approve Resident 4 to receive PT and OT.
During a concurrent interview and record review on 2/25/2025, at 12:40 p.m. with the DOR, Resident 4's care plan titled Resident requires skilled physical therapy ., dated 10/11/2024 was reviewed. The care plan indicated Resident 4 required PT due to decreased strength and endurance. The care plan indicated a goal was for Resident 4 to have an increase in strength to both legs. The care plan indicated Resident 4 would receive therapeutic activities. The DOR stated the care plan was appropriate for Resident 4. The DOR stated Resident 4 still needed PT.
During an interview on 2/25/2025 at 1:05 p.m. with the Director of Nursing (DON), The DON stated the decision to provide PT and/or OT to residents (in general) was not dependent on the residents' (in general) insurance authorization. The DON stated if the resident's PT eval and/or OT eval indicated the resident would benefit from PT and/or OT then the resident should receive PT and/or OT. The DON stated if the care plan indicated the resident (in general) needed PT and/or OT the resident should be provided PT and/or OT.
During a review of the facility's policy and procedure (P&P) titled, Functional Impairment - Clinical Protocol, revised September 2012, the P&P indicated, Upon admission to the facility, at any time a significant change of condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident's physical condition and functional status. The P&P indicated, .A physician, nurse or therapist may initiate screening for the potential to benefit from rehabilitative services such as physical and occupational therapy .Following the screening, the therapist will document whether the resident may benefit from a more detailed rehabilitation evaluation or from unskilled therapy (e.g., restorative nursing services that can be provided by caregivers or exercises with which family members can assist) .If a potential to benefit from rehabilitation therapies (either skilled or unskilled) is identified, the attending physician will order a relevant therapy evaluation (for example, by a physical or occupational therapist) In conjunction with the physician and staff, therapists will propose a rehabilitation or restorative care plan that provides an appropriate intensity, frequency and duration of interventions to help achieve anticipated goals and expected outcomes efficiently using available resources .Based on a review of available information (including results of the evaluation), the physician will determine if a resident meets the criteria for skilled therapy services .The physician will order therapy services based on the above considerations and the therapist's recommendations.
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
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when eight of eight facility dumpsters' lids were open, leaving the top of the dumpste...
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Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when eight of eight facility dumpsters' lids were open, leaving the top of the dumpsters uncovered.
This failure had the potential to negatively impact the health of residents by attracting rodents and pests to the facility, which could carry infectious diseases.
Findings:
During a concurrent observation and interview on 2/20/2025 at 2:40 p.m. with the Director of Food Services and Environmental (DOF), eight dumpsters were observed behind the facility. All the dumpsters had their lids opened. Three of the dumpsters had trash inside. The DOF stated the dumpster lids should be closed because rodents could get inside the dumpsters if left opened.
During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, revised October 2017, the P&P indicated, Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding littler.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the facility ' s Policy and Procedure (P&P) ti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the facility ' s Policy and Procedure (P&P) titled, Answering the Call Light, and Maintenance Service, for 12 of 29 resident rooms (Rooms 112, 114a, 202, 208, 209, 211, 212, 216, 221, 222, 223 and 225) by failing to:
a. Ensure the call lights in the resident rooms were functioning.
b. Ensure the call light was accessible for one resident in room [ROOM NUMBER]a.
These deficient practices had the potential to result in the delay of care for the residents affecting their safety and quality of life.
Findings:
During a concurrent observation and interview on 2/20/2025 at 11:31 am, with Resident 9, Resident 9 stated the call light did not work the night before (2/19/2025). Resident 9 pressed the call light, and the light did not turn on outside of Resident 9 ' s room above the door.
During an observation on 2/20/2025 at 11:35 am, with the Director of Staff Development (DSD) and Maintenance Staff (MS), the facility call lights were checked in 29 resident rooms of the facility. MS checked the call light in room [ROOM NUMBER] and the light did not turn on above the room ' s door in the hallway and there was no light turning on at the call light panel in the nurses ' station. MS checked the call lights in rooms [ROOM NUMBERS], and the lights did not turn on above the rooms ' doors in the hallway. MS checked the call lights in Rooms 202, 208, 209, 211, 212, 216, 221, 222, and 223 and there were no lights turning on at the call light panel in the nurses ' station.
During an observation on 2/20/2025 at 12:08 pm, MS was going to check the call light in room [ROOM NUMBER]a. The call light was observed hanging over an enteral feeding pump (a medical device that is used to deliver nutrients directly into the stomach or small intestine of a person who is unable to take food or liquids orally) on a pole next to the bed, not accessible to the resident lying in bed.
During an interview on 2/20/2025 at 12:11 pm, with the DSD, the DSD stated the call lights should always be placed on the resident ' s good side and within reach. The DSD stated the call lights were the residents ' form of communication if they needed help. The DSD stated it was everyone ' s responsibility to ensure the call lights were working.
During an interview on 2/20/2025 at 4:55 pm, with the Director of Nursing (DON), the DON stated the call lights were provided to the residents so their needs could be met, and their concerns immediately addressed. The DON stated, the resident would not be able to get assistance timely if the call light was not accessible.
During a review of the facility ' s P&P titled, Maintenance Service, revised December 2009, the P&P indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.
During a review of the facility ' s P&P titled, Answering the Call Light, revised in October 2010, the P&P indicated when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Report all defective call lights to the nurse supervisor promptly.
Feb 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one of th...
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Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one of thirteen sampled residents (Resident 12) by failing to:
1. Ensure Housekeeper (HK) 1 timely reported an abuse allegation involving Certified Nursing Assistant (CNA) 3 and Resident 12 to the Housekeeping Supervisor (HS) and/or to the Administrator (ADM).
2. Ensure the facility reported an abuse allegation to the California Department of Public Health (CDPH) immediately but no later than two hours of knowing about the abuse allegation.
These deficient practices had the potential to compromise the safety of Resident 12 and exposed Resident 12 to further potential abuse.
Findings:
During a review of Resident 12's admission Record (AR), the AR indicated the facility originally admitted Resident 12 on 2/15/2023, and readmitted Resident 12 on 4/21/2023, with diagnoses that included hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease (kidney damage caused by high blood pressure), respiratory failure (a serious condition that occurs when the lungs are unable to get enough oxygen into the blood or remove enough carbon dioxide), and muscle weakness.
During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, the MDS indicated Resident 12 was usually understood by others and had the ability to usually understand others. The MDS indicated Resident 12 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene.
During an interview on 2/5/2025 at 11:37 am with HK 1, HK 1 stated five months ago, HK 1 saw CNA 3 sitting on top of Resident 12's bed pulling Resident 12 up towards CNA 3. HK 1 stated HK 1 did not report what HK 1 saw at that time because HK 1 was nervous and did not want anything to happen to CNA 3.
During an interview on 2/5/2025 at 12:38 pm with the ADM, the ADM stated on 12/26/2024, HK 1 reported to the HS that two months prior to 12/26/2024 at 11:30 am, HK 1 allegedly saw CNA 3 kissed Resident 12. The ADM stated the protocol for any abuse allegation was to file a SOC 341 (a confidential report of suspected dependent adult/elder abuse) within two hours (to CDPH) and for the facility to continue the investigation for five days. The ADM stated the abuse allegation was not reported to CDPH because Resident 12 denied the allegation during the facility's investigation. The ADM stated the facility's abuse policy was for staff to report the incident (alleged abuse) right away so the facility could start the investigation and to prevent any harm to the resident. The ADM stated facility staff were aware they had to immediately report all alleged abuse to the ADM so the resident could be protected from harm.
During a follow-up interview on 2/5/2025 at 3:27 pm with HK 1, HK 1 stated five months ago, HK 1 stated HK 1 saw CNA 3 sitting on top of Resident 12's bed, either pulling Resident 12 up towards CNA 3 or hugging Resident 12. HK 1 stated HK 1 should have reported the incident to the HS and/or the ADM right away.
During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The P&P indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The P&P indicated, The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:
a. The state licensing/certification agency responsible for surveying/licensing the facility;
b. The local/state ombudsman;
c. The resident's representative;
d. Adult protective services (where state law provides jurisdiction in long-term care);
e. Law enforcement officials;
f. The resident's attending physician; and
g. The facility medical director.
The P&P indicated, .Immediately is defined as:
a. within two hours of an allegation involving abuse or result in serious bodily injury; or
b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services for three of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services for three of thirteen sampled residents (Residents 1, 2, and 13) as indicated in the facility's policies and procedures (P&P) titled, Neurological Assessment, Charting and Documentation, and Change in a Resident's Condition or Status by failing to:
a. Ensure assigned licensed nurses completed neurological (relating to the functioning of the brain, spine, and nerves) assessments for the 72-hour monitoring period after Resident 1 was involved in a resident-to-resident altercation.
b. Ensure assigned licensed nurses completed neurological assessments for the 72-hour monitoring period after Resident 2 was involved in a resident-to-resident altercation.
c. Ensure assigned licensed nurses monitored and documented Resident 13's condition when Resident 13 tested positive for Covid-19 (a respiratory illness caused by a virus that is easily spread from person to person) and was transferred to the facility's red zone (area designated for residents who tested positive for Covid-19).
These failures had the potential to result in incomplete and improper assessments of potential changes in Resident 1's and Resident 2's neurological status and Resident 13's condition while in the facility's Covid-19 red zone.
Findings:
a. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought) and dementia (a progressive state of decline in mental abilities).
During a review of Resident 1's History & Physical (H&P), dated 7/2/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/3/2024, Resident 1 had severely impaired cognition (ability to understand) and needed supervision or touching assistance (helper provides verbal cue and/or touching/steadying and/or contact guard assistance as the resident completes the activity with assistance provided throughout the activity or intermittently) with personal hygiene (included combing hair, having, washing/drying face and hands) and walking 10 feet in a room, corridor, or similar space.
During a review of Resident 1's Situation-Background-Assessment-Recommendation Communication Form and Progress Note (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/1/2025, the SBAR indicated Resident 1 and Resident 2 had an altercation on 2/1/2025 at 10:30 am. The SBAR indicated Resident 1 went out the wrong door and was struck by Resident 2, sustaining lower lip discoloration. The SBAR indicated neurological checks (neuro checks -assessment that checks the resident's level of consciousness, pupil response, motor functions [hand grasp strength and movement of extremities], pain response, and vital signs with a monitoring frequency (unless specified by the doctor) of every 15 minutes for 1 hour, every 30 min for 4 hours, every 1 hour for 2 hours and then every shift for 72 hours) were being done every shift.
During a review of Resident 1's Care Plan (CP), dated 2/2/2025, the CP indicated Resident 1 had a physical altercation with another resident. The CP goal indicated to avoid complications due to the altercation. The CP interventions included for staff to monitor the resident closely.
During a review of Resident 1's IDT Conference record (IDT - interdisciplinary team, a group of healthcare providers involved in the resident's care), dated 2/3/2025, the IDT indicated the IDT was being conducted due to the resident-to-resident altercation that occurred on 2/1/2025. The IDT indicated Resident 1's body assessment noted left lower lip discoloration and interventions included 72 hours of monitoring.
During a review of Resident 1's Psychiatric Follow-up Note (PFN), dated 2/3/2025, the PFN indicated Resident 1 was seen due to the resident-to-resident altercation. The PFN indicated the plan included for Resident 1 to be observed for deterioration in function.
During an observation on 2/4/2025 at 2:45 pm in the dining room, Resident 1 was sitting up in a chair and had small amount of purplish-gray discoloration on the bottom lip.
During a concurrent interview and record review on 2/4/2025 at 4:32 pm with the Quality Assurance Nurse (QA), Resident 1's Neurological Assessment Flowsheet (NAF- form used to document neurological assessment checks/neuro checks on a resident) started on 2/1/2025 at 10:30 am was reviewed. The NAF indicated documentation was documented through 2/3/2025, during the 3 pm to 11 pm shift, with some lines of documentation missing pain responses and motor function assessment. The QA stated after a resident-to-resident altercation, the 72-hour monitoring included 72 hours of neurological checks, which were charted on the flowsheets, and monitoring for any emotional distress. The QA stated 72 hours from 2/1/2025 at 10:30 am was 2/4/2025 at 10:30 am and the documentation should have been completed through that morning (2/4/2025). The QA stated it was important to do neuro checks to verify the resident was okay and to monitor the resident for any neurological changes.
b. During a review of Resident 2's AR, the AR indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (DM2- elevated blood sugar level) with diabetic chronic kidney disease (damage to the kidneys so they cannot filter blood properly) and major depressive disorder or depression (a persistent sadness and loss of interest in activities that interferes with daily life).
During a review of Resident 2's H&P, dated 10/7/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 2's MDS, dated [DATE], Resident 2 had severely impaired cognition (ability to understand) and was independent walking 10 feet in a room, corridor, or similar space.
During a review of Resident 2's SBAR, dated 2/1/2025, the SBAR indicated Resident 1 and Resident 2 had an altercation on 2/1/2025 at 10:30 am. The SBAR indicated Resident 1 went out the wrong door and was struck by Resident 2. The SBAR indicated Resident 2 sustained left under eye discoloration. The SBAR indicated residents were separated, behavioral monitoring was in place, and neurological checks were being done every shift.
During a review of Resident 2's CP, dated 2/2/2025, the CP indicated Resident 1 had a physical altercation with another resident. The CP goal indicated to avoid complications due to the altercation. The CP interventions included to monitor the resident closely.
During a review of Resident 2's IDT, dated 2/3/2025, the IDT indicated the IDT was conducted due to the resident-to-resident altercation that occurred on 2/1/2025. The IDT indicated Resident 1's body assessment noted left side eye discoloration and interventions included 72 hours of monitoring.
During a review of Resident 2's PFN, dated 2/3/2025, the PFN indicated Resident 2 was seen due to the resident-to-resident altercation. The PFN indicated the plan included to observe Resident 2 for deterioration in function.
During a concurrent observation and interview on 2/4/2025 at 2:59 pm with Resident 2, in Resident 2's room, Resident 2 had dark purple bruising under Resident 2's left eye. Resident 2 stated Resident 1 hit him (Resident 2) with his (Resident 1's) fist. Resident 2 stated the nurses were not doing neuro checks on him.
During a concurrent interview and record review on 2/4/2025 at 4:32 pm with the QA, Resident 2's NAF started on 2/1/2025 at 10:30 am was reviewed. The NAF indicated the NAF was completed through 2/3/2025 during the 3 pm to 11 pm shift. The QA stated after a resident-to-resident altercation the 72-hour monitoring included 72 hours of neurological checks, which were charted on the flowsheets, and monitoring for any emotional distress. The QA stated72 hours from 2/1/2025 at 10:30 am was 2/4/2025 at 10:30 am and the documentation should have been completed through that morning (2/4/2025). The QA further stated it was important to verify the resident was okay and to monitor the resident for any neurological changes.
During an interview on 2/5/2025 at 4:33 pm with the Director of Nursing (DON), the DON stated after a resident-to-resident altercation with physical abuse, including a hit to the head, the facility's process included a charge nurse initiating neuro checks and usually continuing then neuro checks for 48 to 72 hours to make sure the resident was stable. The DON stated neurological assessments were important to identify abnormalities that arise during the observation time. The DON stated documentation should be complete and when neurological assessments were undocumented, staff would lack resident data to evaluate and would not recognize when something was wrong with the resident.
c. During a review of Resident 13's AR, the AR indicated the facility originally admitted Resident 13 on 5/14/2012, and readmitted Resident 13 on 6/6/2024, with diagnoses that included dysphagia (difficulty swallowing) following other cerebrovascular disease (conditions that affect blood flow to the brain), Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills), and dementia (a group of brain disorders that cause a decline in memory, thinking, reasoning, and judgment).
During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13 was rarely/never understood by others and had the ability to rarely/never understand others. The MDS indicated Resident 13 was dependent (helper does all of the effort) on staff for eating, oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene.
During a review of Resident 13's Progress Notes (PN) dated 12/1/2024 to 12/31/2025 and PN dated 1/1/2025 to 2/4/2025, the PN indicated on 12/27/2024 at 9:50 am, Resident 13 tested positive for Covid-19 and Resident 13 was transferred to the facility's Covid-19 red zone. The PN indicated there was no documentation about Resident 13's condition while Resident 13 was in the Covid-19 red zone on:
1. 12/28/2024 during 11 pm to7 am shift, 7 am to 3 pm shift, and 3 pm to 11 pm shift
2. 12/30/2024 during 7 am to 3 pm shift and 3 pm to 11 pm shift
3. 12/31/2024 during 7 am to 3 pm shift and 3 pm to 11 pm shift
4. 1/1/2025 during 7 am to 3 pm shift and 3 pm to 11 pm shift
5. 1/2/2025 during 7 am to 3 pm shift and 3 pm to 11 pm shift
6. 1/3/2025 during 11 pm to 7 am shift, 7 am to 3 pm shift, and 3 pm to 11 pm shift
During a review of Resident 13's PN dated 1/4/2025, timed at 11:14 am, the PN indicated Resident 13 was noted with chest congestion and cough.
During a review of Resident 13's PN dated 1/4/2025, timed at 4:38 pm, the PN indicated Resident 13 was having difficulty breathing and was noted with desaturation (a decrease in blood oxygen levels). The PN indicated Resident 13 was transferred to the General Acute Care Hospital 1 (GACH 1) via 911 (emergency services) at around 4:30 pm.
During a concurrent interview and record review on 2/4/25 at 3:51 pm with the Infection Preventionist (IP), Resident 1's PN dated 12/1/2024 to 12/31/2025 and PN dated 1/1/2025 to 2/4/2025 were reviewed. The IP stated there was no documentation about Resident 13's condition while Resident 13 was in the Covid-19 red zone on 12/28/2024 during 11 pm to7 am shift, 7 am to 3 pm shift, and 3 pm to 11 pm shift, on 12/30/2024 during 7 am to 3 pm shift and 3 pm to 11 pm shift, on 12/31/2024 during 7 am to 3 pm shift and 3 pm to 11 pm shift, on 1/1/2025 during 7 am to 3 pm shift and 3 pm to 11 pm shift, on 1/2/2025 during 7 am to 3 pm shift and 3 pm to 11 pm shift, and on 1/3/2025 during 11 pm to 7 am shift, 7 am to 3 pm shift, and 3 pm to 11 pm shift. The IP stated licensed nurses were supposed to monitor and document the resident's condition every shift for a resident who had a change in condition and for all residents in the Covid-19 red zone.
During an interview on 2/5/2025 at 1:21 pm with the DON, the DON stated the importance of monitoring and documenting a resident's condition after a change in condition was for staff to be able to have a picture of what the resident had, the resident's care and condition, and to recognize signs and symptoms (of a possible health concern). The DON stated if staff identified a change of condition with the resident, staff needed to monitor and document their assessments so the change of condition could be addressed.
During a review of the facility's P&P titled, Neurological Assessment, revised October 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for a neurological assessment . when indicated by the resident's condition. The P&P indicated, The following information should be recorded in the resident's medical record:
1. The date and time the procedure was performed.
2. The name and title of the individual(s) who performed the procedure.
3. All assessment data obtained during the procedure.
During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised May 2017, the P&P indicated The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
During a review of the facility's P&P titled, Charting and Documentation, revised July 2017, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical physical, functional or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure the call bell (device that is used to summon a staff member when needed) for one of three sampled residents (Resident ...
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Based on observation, interview, and record review, the facility failed to ensure the call bell (device that is used to summon a staff member when needed) for one of three sampled residents (Resident 2) was within reach according to the facility's policies and procedures (P&P) titled, Accommodation of Needs, and Answering the Call Light.
As a result of this failure, Resident 2 was unable to reach the call bell when assistance was needed from facility staff. This failure had the potential for Resident 2 to experience pain, distress, a medical emergency, and could lead to psychosocial (mental, emotional, social, and spiritual effects) harm from not being able to call for help when needed.
Findings:
During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/10/2025, with diagnoses that included hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or nerves connected to the affected muscles) and hemiplegia (paralysis of one side of the body) following cerebral infarction (CVA- also known as stroke- disruption of blood flow to the brain due to problematic vessels that cause lack of blood supply and oxygen to the brain), and chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems).
During a review of Resident 2's untitled care plan (CP), initiated 1/14/2025, the CP indicated Resident 2 had impaired circulation (blood flow) related to a stroke on 1/6/2025, with left-sided weakness.
During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool) dated 1/16/2025, the MDS indicated Resident 2 had intact cognition (ability to think, remember, and understand). The MDS indicated Resident 2 was dependent (helper does all the effort) on staff for oral, toileting, and personal hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, sitting to lying (in bed), sitting to standing, and chair/bed-to-chair- transfers.
During a concurrent interview and record review on 1/28/2025 at 10:43 am with Resident 2 and Resident 2's Responsible Party (RP 2), Resident 2's call bell was observed. The call bell was observed on Resident 2's left side, behind Resident 2's pillow. RP 2 stated Resident 2's call bell was on Resident 2's left side. RP 2 stated Resident 2 had a stroke that affected the left side, making it difficult for Resident 2 to use the call bell when it was on Resident 2's left side. Resident 2 stated facility staff (in general) put the call bell on Resident 2's left side, All the time, even though Resident 2 could not reach it when it was on Resident 2's left side. Resident 2 stated it was hard for Resident 2 to get help because Resident 2 could not reach the call bell. Resident 2 stated it made Resident 2 sad at times because Resident 2, Wished I was strong enough on my left side to reach and press, the call bell.
During an interview on 1/28/2025 at 10:52 am with Resident 3, Resident 3 stated Resident 3 was Resident 2's roommate. Resident 3 stated at times staff did not position Resident 2's call bell on Resident 2's right side. Resident 3 stated Resident 2 will tell Resident 3, and Resident 3 will press Resident 3's call bell for Resident 2.
During a concurrent observation and interview on 1/28/2025 at 11:07 am with Licensed Vocational Nurse (LVN) 4, Resident 2's call bell was observed. LVN 4 stated Resident 2's call bell was on the left side of Resident 2's bed behind the pillow. LVN 4 stated Resident 2 was unable to reach the call bell because Resident 2 had left hemiparesis. LVN 4 stated the call bell should be on Resident 2's right side so Resident 2 could call for help when needed. LVN 4 stated this was a safety issue and could lead to pain and discomfort and Resident 2's needs not being met.
During an interview on 1/28/2025 at 12:30 pm with the Director of Nursing (DON), the DON stated if a resident (in general) had left hemiparesis, the resident's call bell should be on the resident's right side and not the left so the resident could ask for help. The DON stated a resident would not be able to ask for help if the call bell was on the resident's left side. The DON stated this could cause a delay in care and stop the resident from getting help in emergency situations and was a safety issue. The DON stated call bells should always be within reach for residents to ask for help when needed.
During a review of the facility's P&P titled, Accommodation of Needs, revised 3/2021, the P&P indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The P&P indicated, The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The P&P indicated, The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. The P&P indicated, .arranging toiletries and personal items so that they are in easy reach of the resident .
During a review of the facility's P&P titled, Answering the Call Light, revised 9/2022, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. The P&P indicated, Ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility to failed ensure two of three sampled residents (Residents 2 an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility to failed ensure two of three sampled residents (Residents 2 and 3) were provided with a safe, clean, comfortable and homelike environment, according to the facility's policy and procedure (P&P) titled, Homelike Environment, by failing to ensure Residents 2 and 3 did not smell the odor of cigarette smoke from facility staff smoking outside Residents 2 and 3's room window.
As a result of this failure, Residents 2 and 3 were unable to keep their room window open throughout the day and were exposed to secondhand smoke (SHS- involuntary inhalation of tobacco [a plant with leaves that have levels of nicotine [addictive, poisonous chemical] that is generally smoked or ingested] smoke, that is a mixture of smoke exhaled by smokers and smoke from burning tobacco products). This failure had the potential for Residents 2 and 3 to develop respiratory illness and could affect Residents 2 and 3's psychosocial (mental, emotional, social, and spiritual effects) well-being from not experiencing fresh air from an open room window.
Findings:
1. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/10/2025 with diagnoses that included left hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or nerves connected to the affected muscles) and hemiplegia (paralysis of one side of the body) following cerebral infarction (CVA- also known as stroke- disruption of blood flow to the brain due to problematic vessels that cause lack of blood supply and oxygen to the brain), and chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems).
During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool) dated 1/16/2025, the MDS indicated Resident 2 had intact cognition (ability to think, remember, and understand). The MDS indicated Resident 2 was dependent (helper does all the effort) on staff for sitting to lying (in bed), sitting to standing, and chair/bed-to-chair- transfers. The MDS indicated going outside to get fresh air when the weather was good was very important to Resident 2. The MDS indicated Resident 2 did not currently use tobacco.
2. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 1/9/2025, with diagnoses that included hyperlipidemia (having too many lipids or fat in the blood) and hypertension (high blood pressure), and generalized anxiety disorder (persistent feeling of dread or panic that can interfere with daily life).
During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had intact cognition. The MDS indicated Resident 3 required partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs but provides less than half the effort) with sitting to lying (in bed), sitting to standing, and chair/bed-to-chair transfers. The MDS indicated going outside to get fresh air when the weather was good was very important to Resident 3. The MDS indicated Resident 3 did not currently used tobacco.
During a concurrent observation and interview on 1/28/2025 at 10:34 am with Resident 2 and Resident 2's Responsible Party (RP 2), Resident 2's room window was observed. RP 2 stated the employee smoking area was right outside of Residents 2 and 3's room window. RP 2 stated Resident 2 like to have the window open because Resident 2 liked the fresh air. RP 2 stated even when the window was closed, it smelled when facility staff smoked because the facility's windows were old. Resident 2 stated the smell of cigarette smoke, Really bothered, Resident 2 because Resident 2 wanted to feel the fresh air because Resident 2 liked being outside but could not at present due to Resident 2's medical condition.
During an interview on 1/28/2025 at 10:52 am with Resident 3, Resident 3 stated the smell of cigarette smoked really bothered Resident 3. Resident 3 stated Resident 3 and Resident 2 liked the smell of fresh air and Hated, when facility staff smoked. Resident 3 stated Resident 3 stopped smoking cigarettes in 1990. Resident 3 stated the facility staff smoking, Has got to go. Resident 3 stated Resident 3 did not get to enjoy the fresh air (from Resident 3's room window) because of the smell of cigarette smoke.
During an observation on 1/28/2025 at 11:03 am, Receptionist (RC) 1 was observed outside of Residents 2 and 3's room window. RC 1 was holding a cigarette that had smoke coming out of the end of the cigarette. There was an odor of smoking coming in through Residents 2 and 3's room window. RC 1 was approximately 15 feet (ft- unit of measurement) from Residents 2 and 3's room window.
During a concurrent observation and interview on 1/28/2025 at 11:12 am with Occupational Therapist (OT) 1, Residents 2 and 3's room window was observed. OT 1 stated RC 1 was holding a cigarette and was smoking. OT 1 stated the area outside of Residents 2 and 3's room window was the facility's designated employee smoking area ([NAME]). OT 1 stated Residents 2 and 3's room smelled of cigarette smoke.
During a concurrent observation and interview on 1/28/2025 at 12:30 pm with the Director of Nursing (DON), the facility's [NAME] was observed. The DON stated if facility staff were smoking in the [NAME], it was possible for Residents 2 and 3 to be exposed to and smell cigarette smoke. The DON stated Residents 2 and 3 not being able to keep their room window open to have fresh air was an accommodation of needs issues because residents had the right keep their windows open and not smell unpleasant odors. The DON stated Residents 2 and 3 could be exposed to SHS.
During a review of the facility's P&P titled, Smoking Policy- Employees, revised 5/2019, the P&P indicated, It is the policy of this facility to provide our employees with as near smoke-free environment as possible and to ensure safe smoking practices for those who smoke. The P&P indicated, Smoking is prohibited in any area that would create a hazardous or unsafe condition.
During a review of the facility's P&P titled, Homelike Environment, revised 2/2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment The P&P indicated, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting. These characteristics include . pleasant, neutral scents .
Dec 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
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the toenails of one of 13 sampled residents (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the toenails of one of 13 sampled residents (Resident 1) were kept trimmed according to the facility's Policy and Procedure (P&P) on Care of Fingernails/Toenails.
This failure placed Resident 1 at risk for injury, infection, or complications from long toenails.
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms), dysphagia (difficulty swallowing), and respiratory failure (when the lungs cannot get enough oxygen into the blood). The AR indicated Resident 1 had a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach).
During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident) dated 2/19/24, the H&P indicated Resident 1 was awake and alert, and occasionally responds to simple questions. The H&P also indicated Resident 1 had hyperglycemia (high blood sugar) and received insulin (a hormone that removes excess sugar from the blood).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 9/2/24, the MDS indicated Resident 1 was dependent on others for oral, personal, and toileting hygiene, for showering/bathing, for dressing, and for putting on/taking off footwear. The MDS indicated Resident 1 was dependent on others to move around in bed, to transfer to and from a bed to a chair or wheelchair, and to get in and out of a tub/shower.
During an observation on 12/26/24 at 1:21 pm, Certified Nursing Assistant 6 (CNA 6) removed Resident 1's socks. As soon as Resident 1's left foot toes were exposed, bleeding was noted from an open area beside the toenail of the second digit. Resident 1 had long toenails on both feet.
During an interview on 12/26/24 at 1:51 pm with Licensed Vocational Nurse 2 (LVN 2), LVN 2 assessed Resident 1's feet. LVN 2 stated Resident 1's toenails were long. LVN 2 cleaned the blood off the open area on Resident 2's left second digit and stated it looked like an ingrown nail that came off.
During an interview on 12/26/24 at 3:20 pm with the Director of Staff Development (DSD), the DSD stated residents' nails were checked daily with care. The DSD stated toenail care was referred to the podiatrist (doctor who specialize in disorders of the feet and ankles), and CNAs were instructed to notify the charge nurse or the supervisor if a resident had long toenails, so that the resident could be placed on the podiatry schedule. The DSD stated CNAs were to trim the resident's nails if the resident was not diabetic.
During an interview on 12/26/24 at 3:34 pm with the Social Services Director (SSD 1), SSD 1 stated podiatry appointment was set by the Nursing Department and then the resident will be placed on the podiatry list. SSD 1 stated Resident 1's spouse and/or the Nursing Department had not informed SSD 1 of any podiatry issues regarding Resident 1. SSD 1 stated Resident 1 will be referred to be seen by a podiatrist.
During an interview on 12/27/24 at 3:45 pm with the Director of Nursing (DON), the DON stated CNAs had to cut the resident's nails as needed. The DON stated, if the resident's toenails were long and the resident was diabetic, the resident was referred to the podiatrist. The DON stated CNAs needed to report to the charge nurse whenever a resident had long nails so the charge nurse could inform social services to include the resident on the podiatry schedule. The DON stated CNAs needed to maintain the resident's nails at a good/safe length and not wait until the resident's nails were long.
During a review of the facility's P&P titled, Care of Fingernails/Toenails, dated 10/2010, the P&P indicated, Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed .Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease .
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 follow its policy to provide a two-person assist when using a mecha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy to provide a two-person assist when using a mechanical lift during the transfer of one of four sampled residents (Resident 14).
This failure placed Resident 14 at risk for a preventable accident and/or injury.
Findings:
During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was readmitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (narrowed blood vessels causing reduced blood flow to limbs) and functional quadriplegia (inability to move due to a severe disability).
During a review of Resident 14's History & Physical (H&P), dated 9/22/24, the H&P indicated Resident 14 did not have the capacity to understand and make decisions.
During a review of Resident 14's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/1/24, the MDS indicated Resident 14 had moderate cognitive impairment (ability to process thoughts and perform various mental activities), lower extremity impairment (loss of physical ability), and was totally independent for chair/bed to chair transfers and tub/shower transfer.
During an interview on 12/23/24 at 6:54 a.m., Licensed Vocational Nurse 3 (LVN 3) stated Resident 14 reported to LVN 3 that Certified Nurse Assistant 3(CNA 3) does not know how to transfer Resident 14. LVN 3 stated the Hoyer lift (electronically operated patient lift) should be used for transferring Resident 14. LVN 3 stated the Hoyer Lift was used to transfer the resident, with a minimum of two staff.
During an interview on 12/23/24 at 7:00 p.m., LVN 3 stated Resident 14 reported that CNA 3 tried to transfer Resident 14 to the shower chair from the bed and CNA 3 could not do it. CNA 3 got the Hoyer lift and CNA 3 transferred Resident 14 by himself alone. Resident 14 told LVN 3 that CNA 3 stepped on Resident 14 ' s toe prior to acquiring the Hoyer lift and this was the reason CNA 3 decided to get the Hoyer lift. Resident 14 told LVN 3 it was only CNA 3 present when transferring Resident 14 with the Hoyer lift.
During an interview on 12/23/24 at 7:04 p.m., with LVN 3, LVN 3 stated using a Hoyer lift was important for the resident and staff due to resident ' s weight or condition and an unsafe transfer of a resident with a Hoyer lift can result to injury to the resident or staff.
During an interview on 12/23/24 at 7:29 p.m., with the Director of Nursing (DON), the DON stated the facility policy for mechanical lift use was not less than two staff and was based on patient ' s weight. The DON stated the purpose of mechanical lift use was for safe movement and lifting of the resident and required assistance.
During an interview on 12/24/24 at 3:45 p.m. with the DON, the DON stated the Hoyer lift was used with minimum 2-3 people depending on the weight of the resident.
During an interview on 12/24/24 at 4:05 p.m., with CNA 3, CNA 3 stated CNA 3 worked in Station 5 on 12/10/24 and CNA 3 knew Resident 14. CNA 3 stated, during shower, Resident 14 needed a Hoyer lift. CNA 3 stated Resident 14 told CNA 3 that Resident 14 wanted the Hoyer lift because it would hurt the resident to move. CNA 3 stated CNA 3 used the Hoyer lift on Resident 14 lift by himself alone. CNA 3 stated the Hoyer lift needed two people to transfer the resident. CNA 3 stated CNA 3 was supposed to get help with Hoyer lift and transfer Resident 14, but CNA 3 could not find any CNA to help him. CNA 3 stated CNA 3 showered Resident 14 alone during the night and CNA 3 used the Hoyer lift.
During a review of the facility ' s Policy & Procedure (P&P), titled, Lifting Machine, Using A Mechanical, dated July 2017, the P&P indicated at least two (2) assistants are needed to safely move a resident with a mechanical lift.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medication to one of 13 sampled residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medication to one of 13 sampled residents (Resident 2) according to the physician's order when Licensed Vocational Nurse 1 (LVN 1) administered Temazepam (a medication to aid sleeping) 7.5 milligrams (mg-a unit of measure) to Resident 2, five (5) hours and 51 minutes before bedtime (9 pm).
This failure resulted in unsafe medication administration and had the potential to negatively impact Resident 2's health, safety, and well-being.
Findings:
During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/20/24, the MDS indicated Resident 2's cognition (ability to think, learn, and understand) was intact. The MDS indicated Resident 2 required substantial/maximal assistance (helper lifted or held trunk or limbs but provided more than half the effort) with showering/bathing and with upper body dressing, and was dependent on others for personal hygiene, putting on/taking off footwear, toileting hygiene, lower body dressing, moving around in bed, and to transfer in and out of bed, and to get in and out of the shower/tub.
During a review of Resident 2's Physician's Order (PO) dated 12/20/24, the PO indicated for licensed staff to administer Temazepam 7.5 mg at bedtime to Resident 2 once every 24 hours as needed for inability to sleep.
During an observation on 12/24/24 at 3:10 pm, LVN 1 administered medication to Resident 2 inside Resident 2's room.
During an interview on 12/24/24 at 3:13 pm with LVN 1, LVN 1 stated LVN 1 administered Resident 2, Temazepam 7.5 mg for sleep because Resident 2 requested for a sleeping pill three (3) times. LVN 1 stated it was allowed to give Resident 2 Temazepam 7.5 mg at that time (12/24/24 at 3:10 pm) because the physician's order indicated Temazepam 7.5 mg could be administered to Resident 2 once every 24 hours. LVN 1 stated medications must be given according to the physician's order. LVN 1 reviewed Resident 2's physician order for Temazepam 7.5 mg and stated bedtime medications must be administered after 9 pm.
During a review of Resident 2's Medication Administration Record (MAR) dated 12/1/24-12/31/24, the MAR indicated LVN 1 administered Temazepam 7.5 mg to Resident 2 on 12/24/24 at 3:09 pm.
During an interview on 12/27/24 at 3:45 pm with the Director of Nursing (DON), the DON stated bedtime medication must be given at 9 pm unless a specific time was ordered by the physician.
During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 provide a sanitary (clean) environment to prevent the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a sanitary (clean) environment to prevent the spread of infection for nine of 13 sampled residents (Residents 1, 2, 5, 6, 7, 9, 10, 12, and 13) during a Coronavirus Disease 2019 (COVID-19, an illness caused by a virus that can spread from person to person) outbreak (OB-two or more linked cases of the same illness or the situation where the observed number of cases exceeds the expected number, or a single case of a disease caused by a microorganism), by failing to:
1. Perform hand hygiene appropriately.
2. Implement Enhanced Barrier Precaution (EBP-an infection control intervention designed to reduce the transmission of multidrug-resistant organisms [MDROs] in the nursing home).
3. Post Enhanced Barrier Precaution sign outside the room of residents who required EBP.
4. Wear N95 masks (a respiratory protective device designed to have a very close facial fit over the nose and the mouth, and filters airborne particles) correctly during a COVID-19 outbreak.
These deficient practices had the potential to spread COVID-19 and or other infection to the residents, staff, and visitors that could lead to hospitalization and or death.
Findings:
1a. During an observation on 12/24/24 at 3:10 pm, Licensed Vocational Nurse 1 (LVN 1) handed Resident 2 a medication cup while LVN 1 stood at Resident 2's bedside. Resident 2 took the medication inside the medication cup and handed the medication cup back to LVN 1. LVN 1 exited Resident 2's room, did not wash hands nor use alcohol-based hand rub (ABHR) or hand sanitizer, and walked towards the nurses' station.
During an interview on 12/24/24 at 3:13 pm with LVN 1, LVN 1 stated LVN 1 must use ABHR before going in and after exiting a resident's room. LVN 1 stated it was important to sanitize the hands before and after contact with a resident to prevent the spread of infection.
1b. During an observation on 12/26/24 at 12:19 pm in the COVID-19 isolation area of the facility (area of the facility for residents who have confirmed COVID-19), Certified Nursing Assistant 4 (CNA 4) came out of Residents 9 and 10's room. CNA 4 removed CNA 4's gown and gloves, did not wash hands nor use ABHR, went inside the COVID-19 isolation area's breakroom and washed hands in the restroom inside the breakroom.
During an interview on 12/26/24 at 12:21 pm, CNA 4 stated CNA 4 was supposed to sanitize hands after exiting the residents' room and wash hands. CNA 4 stated CNA 4 did not use ABHR because CNA 4 was allergic to hand sanitizer.
1c. During an observation on 12/26/24 at 12:50 pm, CNA 5 entered Resident 6's room without using ABHR. CNA 5 approached Resident 6 who was sleeping in bed, touched Resident 6's left shoulder and told Resident 6 it was time to eat lunch. CNA 5 assisted Resident 6 to sit-up in bed then CNA 5 went inside the restroom in Resident 6's room and washed hands. CNA 5 came out of the restroom and assisted Resident 6 with lunch.
During an interview on 12/26/24 at 1:31 pm with CNA 5, CNA 5 stated CNA 5 must use ABHR prior to going inside Resident 6's room.
1d. During an observation on 12/26/24 at 1:09 pm, CNA 6 came out of Resident 5's room carrying Resident 5's lunch tray. CNA 6 did not use ABHR nor washed hands after exiting Resident 5's room. CNA 6 placed Resident 5's tray inside the lunch cart then went inside Resident 4's room without using ABHR and or washed CNA 6's hands. CNA 6 came out of Resident 4's room with Resident 4's lunch tray and without using ABHR, CNA 6 placed Resident 4's tray inside the lunch cart. CNA 6 went inside Resident 12's room without using ABHR nor washed CNA 6's hands. CNA 6 came out of Resident 12's room with Resident 12's lunch tray without using ABHR nor washing hands, placed Resident 12's tray inside the lunch cart, did not use ABHR, and approached CNA 1. CNA 1 was observed at the doorway of Resident 13's room and asked CNA 6 for incontinent briefs for Resident 13. CNA 6 opened the door to the supply storage next to Resident 13's room, got incontinent briefs from the supply storage and handed the incontinent briefs to CNA 1. CNA 6 still have not used ABHR and or washed hands the entire time of observation.
During an interview on 12/26/24 at 1:14 pm with CNA 6, CNA 6 stated CNA 6 did not have to sanitize and or washed hands when picking resident trays if CNA 6 did not touch anything else inside the resident's room.
2a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms), dysphagia (difficulty swallowing), and respiratory failure (when the lungs cannot get enough oxygen into the blood). The AR indicated Resident 1 had a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach).
During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident) dated 2/19/24, the H&P indicated Resident 1 was awake and alert, and occasionally responds to simple questions. The H&P also indicated Resident 1 had hyperglycemia (high blood sugar) and received insulin (a hormone that removes excess sugar from the blood).
During a review of Resident 1's Physician's Order (PO) dated 8/29/24, the PO indicated for staff to place Resident 1 on EBP because Resident 1 had a gastrotomy tube.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 9/2/24, the MDS indicated Resident 1 was dependent on others for oral, personal, and toileting hygiene, for showering/bathing, for dressing, and for putting on/taking off footwear. The MDS indicated Resident 1 was dependent on others to move around in bed, to transfer to and from a bed to a chair or wheelchair, and to get in and out of a tub/shower.
During an observation on 12/24/24 at 2:45 pm, there was no sign for EBP posted outside Resident 1's room.
During a concurrent observation and interview on 12/26/24 at 1:15 pm, CNA 6 went inside Resident 1's room without using ABHR and or washing hands, and without a protective gown on. CNA 6 lifted Resident 1's blanket to remove Resident 1's socks. When asked if CNA 6 needed to use ABHR and put a gown on first, CNA 6 stated CNA 6 was supposed to use ABHR before touching Resident 1, but CNA 6 was in a rush. CNA 6 stated it was important to sanitize and or wash hands to prevent cross contamination (transfer of harmful bacteria from one person, object, or place to another). CNA 6 stated CNA 6 was supposed to wear a gown before touching Resident 1 because Resident 1 had a gastrostomy tube and on EBP, but CNA 6 forgot because CNA 6 did not see an EBP sign outside Resident 1's room.
During a concurrent observation and interview on 12/27/24 at 10:48 am, Social Services Designee (SSD 2) and CNA 8 were observed inside Resident 1's room without a protective gown on and with their N95 masks not worn correctly. SSD 2's N95 mask did not cover SSD 2's nose and CNA 8's N95 mask was not fitted around CNA 8's nose bridge. SSD 2 and CNA 8 stated it was important to have N95 masks on to protect themselves from infection. SSD 2 stated SSD 2 did not put on a gown because SSD 2 did not come close to Resident 1 and was only doing an inventory of Resident 1's belongings. CNA 8 stated CNA 8 did not notice the EBP sign outside Resident 1's room and started cleaning Resident 1 up without a gown until CNA 8 saw Resident 1 had a gastrostomy tube.
2b. During a review of Resident 7's AR, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included ESRD (End Stage Renal Disease-irreversible kidney failure) and with multiple wounds on both lower extremities. Resident 7 required hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).
During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 was dependent on others for toileting and personal hygiene, for showering/bathing, for dressing, for putting on/taking off footwear, for bed mobility, to transfer in and out of bed to wheelchair and wheelchair to bed, and to get in and out of tub/shower.
During a review of Resident 7's PO dated 12/27/24, the PO indicated for staff to place Resident 7 on EBP because Resident 7 had a dialysis catheter on the right upper chest.
During a concurrent observation in Resident 7's room and interview on 12/27/24 at 11:20 am, there was no EBP sign posted outside Resident 7's room. Dialysis Technician 1 (DT 1) was working with the hemodialysis machine at Resident 7's bedside without a protective gown on and the bottom strap of DT 1's N95 mask was loosely hanging under DT 1's chin. DT 1 came out of Resident 7's room without using ABHR and or washing hands and walked towards the nurses' station. When asked, DT 1 stated DT 1 should sanitize hands before and after handling the dialysis machine and before and after providing care to a resident. DT 1 stated DT 1 needed to wear N95 mask correctly to prevent the spread of infection. DT 1 stated DT 1 needed to put on a gown when providing care to residents with a dialysis catheter.
3. During a concurrent observation and interview on 12/27/24 at 10:46 am, LVN 4 was observed in Station 4's nurses' station with LVN 4's N95 mask pulled down to LVN 4's chin. LVN 4 stated LVN 4 was required to have an N95 mask on because of the facility's current COVID-19 OB. LVN 4 stated it was important to wear N95 mask on correctly to prevent the spread of COVID-19.
During a concurrent observation and interview on 12/27/24 at 11:28 am, LVN 5's N95 mask was observed with both straps behind LVN 5's neck. LVN 5 stated LVN 5 had to wear N95 mask because of the facility's current COVID-19 OB. LVN 5 stated it was important to wear the N95 mask on correctly to prevent the spread of infection and to protect myself as well. LVN 5 stated the top strap of N95 mask was supposed to be on the back of my head and not behind the neck.
During a concurrent observation and interview on 12/27/24 at 11:34 am, the Registered Nurse Supervisor's (RNS) N95 mask was missing a bottom strap. The RNS stated RNS needed to wear an N95 mask because of the facility's current COVID-19 OB. The RNS stated the bottom strap of RNS's N95 mask broke when RNS removed a gown earlier and whenever RNS removed RNS's eyeglasses. The RNS stated the N95 mask strap easily breaks. The RNS stated it was important to wear N95 mask on correctly for good seal to prevent possible exposure (to COVID-19) and contamination.
During an observation on 12/27/24 at 11:50 am, Respiratory Therapist 1's (RT 1) N95 mask was missing a bottom strap. RT 1 went inside Resident 8's room to assist another female staff (unknown) with Resident 8.
During a concurrent observation and interview on 12/27/24 at 11:59 am, CNA 9 was observed in the hallway of Station 2 with N95 mask not fitted around the nose bridge. CNA 9 tried to fix CNA 9's N95 mask but did not know how to fit the N95 mask around the nose bridge.
During an interview on 12/27/24 at 12:03 pm with RT 1, RT 1 stated the N95 mask straps broke off a lot. RT 1 stated RT 1 had to wear an N95 mask because of the facility's current COVID-19 OB. RT 1 stated N95 mask had to fit properly to prevent the spread of infection.
During an observation on 12/27/24 at 12:24 pm, Laundry Staff 1 (LS 1) was observed with N95 mask down to LS 1's neck while LS 1 locked a door located in between rooms [ROOM NUMBERS].
During an interview on 12/27/24 at 3:20 pm with the facility's Infection Prevention Nurse (IPN), the IPN stated the IPN was aware there were EBP signs that were not posted outside the residents' rooms. The IPN stated Station 2 staff (general) informed IPN today (12/27/24) that the N95 mask straps easily broke. The IPN stated all facility staff were trained on how to properly put on N95 mask during N95 fit testing.
During an interview on 12/27/24 at 3:45 pm with the Director of Nursing (DON), the DON stated the DON expected all staff to prevent the spread of infections and to mitigate infection. The DON stated it was important to perform hand hygiene, wear personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments), follow isolation precautions, and to follow the proper use of PPE. The DON stated the expectation was higher due to the facility's current COVID-19 OB.
During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated 8/2022, the P&P indicated, EBPs employ targeted gown and glove use during high contact resident care activities .examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care .EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required .
During a review of the facility's P&P titled, Coronavirus Disease (COVID-19) - Source Control, dated 9/2022, the P&P indicated, Source control measures are utilized as part of the infection prevention and control measures during the COVID-19 pandemic. Source control refers to the use of well-fitting .facemasks or respirators that cover the mouth and nose and prevents the spread of respiratory secretions when individuals are breathing, talking, sneezing, or coughing .Source control options for staff include a NIOSH-approved particulate respirator with N95 filters or higher .
During a review of the facility's undated guide on how to properly put N95 mask on, titled, Sequence for Putting on Personal Protective Equipment (PPE), the guide indicated, Mask or Respirator: secure ties or elastic bands at middle of head and neck, fit flexible band to nose bridge, fit snug to face and below chin, and fit-check respirator .
During a review of the facility's P&P titled, Handwashing/Hand Hygiene ., dated 8/2019, the P&P indicated, Use an alcohol-based hand rub or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .before and after direct contact with residents .after contact with objects in the immediate vicinity of the resident .before and after entering isolation precaution settings .before and after assisting a resident with meals .hand hygiene is the final step after removing and disposing of personal protective equipment .
Dec 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the care and services for one of 14 sampled residents (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 provide the care and services for one of 14 sampled residents (Resident 11), according to the facility's policy and procedure (P&P) titled Referrals, Social Services, by failing to:
Ensure when Nurse Practitioner (NP) 1's direct referral (referral for a specialist made by a prescribing healthcare provider with an authorization provided before the appointment is scheduled) made on 6/19/2024 for Resident 11 to be assessed by an endocrinologist (medical professional who specializes in diagnosing and treating conditions caused by issues with the endocrine system, which is made up of glands and organs that produce hormones) for treatment of uncontrolled type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel) appointment was made promptly by Registered Nurse (RN) 2.
As a result of this failure, an appointment for the endocrinologist was not scheduled until 10/8/2024 for 2/12/2025. Resident 11's DM2 remained uncontrolled from 1/2024 to 11/2024. Resident 11's blood glucose (BG- also known as blood sugar, is the amount of sugar in the blood measured in milligrams per deciliter [mg/dL] with normal BG ranging from 70-99 mg/dL) levels were hyperglycemic (BG greater than 100 mg/dL) putting Resident 11 at risk for complications from DM2.
Findings:
During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included DM2, dementia (progressive states of decline in mental abilities), and Hypertensive Heart Disease (Chronic changes in the left ventricle and atrium, and coronary arteries as a result of chronic raised blood pressure).
During a review of Resident 11's Laboratory Report (LR) dated 2/22/2024, the LR indicated Resident 11's BG was 315 mg/dL. The LR indicated Resident 11's A1C (measures the average amount of glucose in the blood over two or three months with normal A1C ranging from 0-5.7 percent [%]) was 9.5 %.
During a review of Resident 11's Order Summary Report (OSR) for active orders as of 11/2024, the OSR indicated and order on 6/3/2024 for Resident 11 to have an endocrinology consult due to abnormal A1C.
During a review of Resident 11's LR dated 6/4/2024, the LR indicated Resident 11's BG was 173 mg/dL. The LR indicated Resident 11's A1C was 9.9 %.
During a review of Resident 11's Annual History and Physical (AHP) dated 6/18/2024 at 12:21 pm, the AHP indicated Resident 11 had high blood sugars (BG). The AHP indicated Resident 11 had not yet been scheduled for an endocrinology appointment. The AHP indicated NP 1 would enter a direct referral for Resident 11 to be seen by an endocrinologist. The AHP was signed by NP 1.
During a review of Resident 11's OSR, the OSR indicated on 6/19/2024 a order to schedule Resident 11 for an appointment with endocrinology. The order indicated an authorization number indicating Resident 11 had been approved to see the endocrinologist.
During a review of Resident 11's Progress Notes (PN) dated 6/19/2024 at 3:56 am, the PN indicated RN / received new orders to received by the previous shift to schedule Resident 11 an appointment with endocrinology. The PN indicated the order was noted noted and carried out. The PN indicated RN/authored the note.
During a review of Resident 11's minimum data set (MDS- a resident assessment tool) dated 10/1/2024, the MDS indicated Resident 11 had moderately impaired cognition (ability to think, remember, and reason).
During a review of Resident 11's PN dated 10/2/2024 at 4:26 pm, the PN indicated Resident 11 was seen by NP 1. The PN indicated to schedule Resident 11 for an appointment for the endocrinologist.
During a review of Resident 11's LR dated 10/3/2024, the LR indicated Resident 11's A1C was 9.4 %.
During a review of Resident 11's PN dated 10/8/2024 at 3:06 pm, the PN indicated Resident 11 was scheduled an appointment for endocrinology on 2/12/2025 at 9:30 am. The PN indicated RN 2 scheduled the appointment and authored the note.
During a telephone interview on 12/12/2024 at 10:53 am, with NP 1, NP 1 stated Resident 11 was NP 1's patient. NP 1 stated NP 1 sees Resident 11 approximately once a month. NP 1 stated since the beginning of the year (2024), NP 1 noticed Resident 11's BG and A1C labs were getting worse. NP 1 stated NP 1 would adjust Resident 11's insulin (medication used to help the body turn food into energy and control blood-sugar levels) but needed to make sure Resident 11's kidneys were not going to be negatively affected. NP 1 stated NP 1 wanted endocrinology to take over Resident 11's DM2 care and assist in controlling Resident 11's BG because Resident 11's DM2 required more specialized management because Resident 11's was not well controlled. NP 1 stated NP 1 would obtain authorizations and the facility would not schedule appointments for Resident 11 to go to theendocrinologist. NP 1 stated NP 1 had been referring Resident 11 to go to the endocrinologist since before 6/2024.
During a concurrent interview and record review on 12/12/2024 at 2:56 pm, with RN 2, Resident 11's BG levels were reviewed. RN 2 normal BG levels were between 60 and 100 mg/dL. RN 2 stated between 1/2024 and 11/2024, Resident 11's BG level ranged between 153 and 398 mg/dL. RN 2 stated Resident 11's BG levels were high and not within normal range. RN 2 stated Resident 11's DM2 was not well controlled. RN 2 stated uncontrolled DM2 could lead to hypertension (chronic elevated blood pressure) and affects the heart and circulation (flow and movement of body throughout the body and to organs and tissue). RN 2 stated circulation could be decreased meaning less blood travels through the vessels. RN 2 stated poor circulation could lead to a heart attack (life-threatening medical emergency that occurs when blood flow to the heart muscle is blocked). RN 2 stated having uncontrolled DM2 and poor circulation could lead to delayed healing because less blood and oxygen travels through the blood vessels and could lead to diabetic foot ulcers (open sores that develop on the feet due to poor circulation, nerve damage from chronic high BG) and other wounds. RN 2 stated if DM2 was affecting Resident 11's body, then Resident 11's body could not carry health blood to areas that needed healing, leading to more wounds.
During the same interview and record review with RN 2, Resident 11's OSR and PN dated 6/2024 to 10/2024 were reviewed. RN 2 stated (in general) when RN 2 received an order for a resident to be scheduled for an appointment, RN 2 was supposed to inform social services to assist in scheduling residents for appointments, but that RN 2 was also able to schedule residents for appointments. RN 2 stated RN 2 was only able to schedule residents for appointments when RN 2 was working the nursing station for the residents RN 2 was scheduling for. RN 2 stated RN 2 attempted several times to schedule Resident 11 for an endocrinology appointment, but could not be on the phone long enough to wait for the appointment to be scheduled. RN 2 stated RN 2 received several orders from NP 1 to schedule Resident 11 for an endocrinology appointment over the course of the year (2024). RN 2 stated on 6/19/2024, RN 3 endorsed during shift change to RN 2 that Resident 11 needed to be scheduled for an endocrinology appointment and that a direct referral had been made. RN 2 stated RN 2 knew Resident 11 needed be scheduled for an endocrinology appointment for several months. RN 2 stated RN 2 only worked in the nursing station where Resident 11 lived two days a week and could only attempt to schedule appointments for Resident 11 during those two days. RN 2 stated RN 2 did not reach out to other nursing staff or social services to assist in scheduling Resident 11 for the endocrinology appointment. RN 2 stated on 10/18/2024, RN 2 scheduled Resident 11 for an endocrinology appointment for 12/12/2025. RN 2 stated Resident 11 needed to be seen by endocrinology so Resident 11's endocrine function and DM2 could be managed properly. RN 2 stated it was important for Resident 11 be scheduled for an endocrinology appointment as soon as Resident 11 received the order so Resident 11 could get treatment as soon as possible. RN 2 stated the delay in scheduling the appointment caused Resident 11 to have a delay in care and treatment could lead to a worsening of Resident 11's condition.
During a concurrent interview and record review on 12/12/2024 at 4:10 pm, with the Social Services Director (SSD), Resident 1's PN were reviewed. The SSD stated (in general), during the daily morning clinical meeting, nursing staff would review what happened on the previous shift. The SSD stated they take note of any resident appointments that need to be scheduled and work towards scheduling the appointment. The SSD stated nursing staff needed to inform social services if they were having difficulty in scheduling appointments so social services could follow up for them. The SSD stated they could look for the order in the resident's electronic health record (EHR) and verify it before scheduling the appointment. The SSD stated if need for the appointment was not discussed in the daily morning clinical meeting or nursing staff did not reach out for assistance, they would not know about it. The SSD stated if no progress notes from 6/19 to 10/8 regarding the need for endo appointment, then it ' s most likely nursing did not bring up the need in the morning clinical meeting and did not inform social services about the need for the appointment in the first place.
During an interview on 12/13/2024 at 3:44 pm, with the Director of Nursing (DON), the DON stated the process for when nurses get orders to schedule residents for an appointment, was for the nurses to make a request to and inform social services so social services could make a request for transportation and assist in scheduling the appointment if needed. The DON stated nursing staff were supposed to communicate with social services if assistance was needed. The DON stated nurses needed to call and schedule the appointment as soon as they received the order to do so. The DON stated it was important to schedule the appointment as soon as possible because the appointment need was related to the resident's condition and to ensure residents were properly assessed. The DON stated normal A1C levels were between 5 and 7 %. The DON stated normal BG levels were between 90 and 130 mg/dL and anything other was considered hyperglycemia. The DON stated it was not safe Resident 11 to be in a constant state of hyperglycemia because it could negatively affect Resident 11's condition. The DON stated if Resident 11's BG was high, the facility needed to follow the hyperglycemia protocol. The DON stated it was not acceptable for Resident 11 to wait four months for an endocrinology appointment to be scheduled when a request was made on 6/19/2024. The DON stated Resident 11 had high BG and needed to be seen by endocrinology as soon as possible to address the issue. The DON stated Resident 11's complications of constant hyperglycemia and elevated A1C, could be diabetic ketoacidosis (DKA- serious and potentially life-threatening complication of DM that occurs when the body does not have enough insulin to use blood sugar for energy), circulation problems like diabetic ulcers due to the impediment of blood flow restricting wound healing, sepsis (the body's extreme response to infection and a life-threatening medical emergency), unresponsiveness, and death.
During a review of the facility's P&P titled, Referrals, Social Services, revised 12/2008, the P&P indicated the facility's social services shall coordinate most resident referrals with outside agencies. The P&P indicated exceptions might include emergency or specialized services that are arranged directly by a physician or the nursing staff. The P&P indicated social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.
During a review of the facility's P&P titled, Diabetes- Clinical Protocol, the P&P indicated the physician would help identify individuals with elevated blood sugar, impaired glucose tolerance, or confirmed diabetes. The P&P indicated the physician would follow up on any acute episodes associated with a significant sustained changed in blood sugars or significant deterioration of previous glucose control and document resident status at the subsequent visits until the acute situation is resolved.
The facility was unable to provide a hyperglycemia protocol.
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 maintain accurate and timely medical records for one of fourteen sa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain accurate and timely medical records for one of fourteen sampled residents (Resident 11), based on the facility's policy and procedure (P&P) titled, Charting and Documentation, and Change in a Residents Condition or Status, by failing to:
1. Ensure when Resident 11 had a change in condition (CIC- a change in the resident's health or functioning that requires further assessment and intervention) on 11/6/2024 4:26 pm, Licensed Vocational Nurse (LVN) 7, filled out the eINTERACT/situation-background-assessment-recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations) form that day and not on 11/10/2024 at 4:54 pm.
2. Ensure when Resident 11 had a CIC on 11/6/2024 at 4:46 pm, LVN 7 accurately documented Resident 11 developed a diabetic foot ulcer (DFU- open sore that develop on the feet due to poor circulation, nerve damage from chronic high [BG- level of sugar in the blood]) on the right foot and not the left foot.
3. Ensure when Resident 11 had a CIC 11/26/2024 at 11 am, LVN 3 documented the CIC on the SBAR form that day and not on 12/2/2024 at 12:33 pm, after Resident 11 had been sent to the general acute care hospital (GACH) 1 on 11/26/2024.
These failures had the potential for Resident 11 to not receive the care, treatment and services needed to treat Resident 11's DFU, and had the potential for Resident 11 to not receive the appropriate monitoring after developing a CIC.
Findings:
During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel), dementia (progressive states of decline in mental abilities), and Hypertensive Heart Disease (Chronic changes in the left ventricle and atrium, and coronary arteries as a result of chronic raised blood pressure).
During a review of Resident 11's minimum data set (MDS- a resident assessment tool) dated 10/1/2024, the MDS indicated Resident 11 had moderately impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 11 substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and toilet transfers. The MDS indicated Resident 11 required partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs, but provides less than half the effort)with oral, toileting and personal hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, tub/shower transfers, and walking 150 feet.
During a late entry SBAR form note dated 11/10/2024 at 4:46 pm, effective date 11/6/2024 at 4:26 pm, the SBAR form indicated Resident 11 was noted with a fluid-filled blister (fluid-filled sac in the outer layer of skin. It can be caused by rubbing, heat, or diseases of the skin) to the left heel (back of foot).
During a review of Resident 11's Order Summary Report (OSR), the OSR indicated on 11/6/2024, Resident 11 had an order for right heel DFU to cleanse with normal saline (sterile salt water), pat dry, apply skin prep and cover with skin prep, daily for 21 days.
During a late entry SBAR form note dated 12/2/2024 at 12:33 pm, effective date 11/26/2024 at 11 am, the SBAR form indicated the wound physician noted Resident 11's right heel DFU was not improving and continued to decline. The recommendation was for Resident 11 to be sent out to GACH 1 for further evaluation.
During a concurrent interview and record review on 12/12/2024 at 2:32 pm, with LVN 3, Resident 3's SBAR effective dated 11/26/2024 and OSR were reviewed. LVN 3 stated (in general) when a resident has a CIC, LVN 3 was supposed to complete the SBAR form by the end of the shift to ensure everything was documented and no points had been forgotten. LVN 3 stated nursing staff were supposed to monitor the resident for 72 hours (three days). LVN 3 stated if the SBAR form was not completed before the end of shift and was not completed until days later, it could lead to care not completed correctly or appropriately for the resident, their condition could decline and get worse. LVN 3 stated on 11/26/2024, Resident 11 had a CIC for DFU, but LVN 3 got busy and forgot to document the SBAR form until six days later. LVN 3 stated it was important to document when needed so LVN 3 could remember all events that took place and to ensure accuracy.
During concurrent observation and interview on 12/13/2024 at 1:45 pm, with LVN 7, Resident 11's SBAR effective dated 11/6/2024, progress notes (PN), and OSR dated 11/6/2024 were reviewed. LVN 7 stated (in general) when a resident had a CIC, LVN 7 was supposed to fill out the SBAR form right away because the resident's condition could decline quickly and nursing staff needed to be able to monitor changes, provide interventions. LVN 7 stated if the CIC is not monitored the resident's condition could deteriorate. LVN 7 stated a lot of residents have comorbidities like DM2. LVN 7 stated Resident 11's SBAR form that was created 11/10/2024 was supposed to be for 11/6/2024. LVN 7 stated it was created late. LVN 7 stated the SBAR for Resident 11's CIC was documented four days after the CIC happened. LVN 7 stated the CIC was made for a fluid-filled blister to the left heel. LVN 7 stated the treatment order was for the right heel. LVN 7 the SBAR form was supposed to be for the right heel because Resident 11 already had a DFU on the left heel. LVN 7 stated there was not monitoring documented in Resident 11's PN because the SBAR form was not created until 11/10/2024. LVN 7 stated if there was not monitoring them Resident 11 ran the risk of the right heel DFU getting worse. LVN 7 stated it was important to document the accurate body part on Resident 11's SBAR form so staff knew what they were supposed to be monitoring otherwise it was possible the resident might not get the accurate monitoring or treatment.
During an interview on at 3:44 pm, with the Director of Nursing (DON), the DON stated all SBAR forms needed to be documented accurately. The DON stated Resident 11's SBAR form effective date 11/6/2024 should be for a right heel DFU and not the left heel. The DON stated the incorrect documentation could affect Resident 11 by not receiving the appropriate treatment due to incorrect documentation. The DON stated any SBAR form created for a resident CIC needed to be filled out the same day as the CIC. The DON stated if a SBAR form for a CIC was not documented the same day as the CIC, it was possible Resident 11 would not receive the appropriate monitoring or treatment. The DON stated all documentation needed to be accurately, complete, and written in a timely manner.
During a review of the facility's P&P titled, Charting and Documentation, revised 7/2027, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The P&P indicated the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.
During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact/SBAR Communication form. The P&P indicated the nurse would record the resident's medical record information relative to the changes in the resident's medical/mental condition or status.
Dec 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain comfort and skin integrity for one of two sampled residents (Resident 1) by:
1. Keeping a mechanical lift sling (a h...
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Based on observation, interview, and record review, the facility failed to maintain comfort and skin integrity for one of two sampled residents (Resident 1) by:
1. Keeping a mechanical lift sling (a harness that supports and wraps around a patient on a device that is used to transfer a patient from one place to another) under Resident 1 for more than six hours while on a low air loss mattress (LALM - a mattress designed to prevent and treat pressure ulcers [bed sores]).
2. Using incorrect bedding for Resident 1's LALM.
This deficient practice had the potential to worsen Resident 1's pressure ulcer.
Findings:
During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/2/2024 with diagnoses of acute (sudden onset) and chronic (continuing for a long time) respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body) with hypoxia (low levels of oxygen in the body tissues), end stage renal disease (irreversible kidney failure), and pressure ulcer of sacral region (the triangular-shaped bone at the base of the back), stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone).
During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 10/8/2024, the MDS indicated Resident 1 was understood by others and had the ability to understand others. The MDS indicated Resident 1 was dependent (helper does all of the effort) on oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 1 was at risk of developing pressure ulcers/injuries.
During a review of Resident 1 ' s Care Plan (CP), dated 10/13/2024, the CP indicated Resident 1 had the potential for pressure ulcer development related to disease process. The CP indicated an intervention was to have the bed as flat as possible to reduce shear (a combination of downward pressure and friction). The CP indicated an intervention was to follow facility policies/protocols for the prevention/treatment of skin breakdown.
During a review of Resident 1 ' s Order Summary Report (OSR), dated 12/5/2024, the OSR indicated Resident 1 had a treatment order for a sacrococcyx (pertaining to both the sacrum and coccyx (the tailbone) pressure ulcer. The OSR indicated Resident 1 had an order for LALM to be set according to the resident ' s weight/comfort.
During a concurrent observation and interview on 12/4/2024 at 12:59 pm, with Certified Nursing Assistants (CNA) 2 and 3, CNA 2 and CNA 3 both walked into Resident 1 ' s room to weigh Resident 1 using the mechanical lift. CNA 2 stated the CNAs started doing the weights at 6:30 am on 12/4/2024. CNA 2 stated Resident 1 was a patient on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). CNA 2 stated the reason they left the sling under Resident 1 since that morning was so they could weigh Resident 1 again in the afternoon.
During an interview on 12/4/2024 at 2:55 pm, with Resident 1, Resident 1 stated staff would leave the sling under Resident 1 for too long. Resident 1 stated the sling hurt and made Resident 1 uncomfortable especially during dialysis treatment because Resident 1 was unable to move. Resident 1 stated staff weighed Resident 1 in the morning before dialysis and weighed Resident 1 again in the afternoon after dialysis.
During an interview on 12/5/2024 at 3:09 pm, with Licensed Vocational Nurse (LVN) 7, LVN 7 stated LVN 7 had noticed that CNAs were keeping the sling under Resident 1. LVN 7 stated LVN 7 had noticed it happen twice. LVN 7 stated leaving the sling under the resident could cause pressure on the resident with the strap being twisted a certain way.
During a concurrent observation and interview on 12/5/2024 at 3:21pm, with LVN 7, Resident 1 ' s LALM was observed to be covered with a fitted sheet. LVN 7 stated there should only be a flat sheet or a single layer sheet when on the LALM. LVN 7 stated having the fitted cover sheet would prevent the LALM from functioning.
During an interview on 12/5/2024 at 4:22 pm, with the Director of Nursing (DON), the DON stated staff was supposed to take out the sling after weighing the resident. DON stated the sling should not be left under the resident. DON stated the sling would cause discomfort for the resident. DON stated there should only be one flat sheet and no more than two layers on a LALM because it would defeat the purpose of the LALM for skin integrity.
During a review of the facility ' s policy and procedure (P&P), titled, Lifting Machine, Using a Mechanical, revised in July 2017, the P&P indicated the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. Steps in the procedure included to lift the resident 2 inches from the weight distribution. Check the resident ' s comfort level by asking or observing for signs of pinching or pulling of the skin. Slowly lift the resident. Only lift as high as necessary to complete the transfer. Gently support the resident as he or she is moved, but do NOT support any weight. When the transfer destination is reached, slowly lower the resident to the receiving surface. Once the resident's weight is released, stop the lowering and ensure that the sling bar does not hit the resident. Detach the sling from the lift. Carefully remove the sling from under the resident. Be mindful of the resident's position and balance, and skin.
The P&P for LALM was requested from the facility on three occasions and was not provided.
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 F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Answe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Answering the Call Light, for two of two sampled residents (Resident 1 and Resident 3) by failing to:
1. Ensure Resident 1 ' s call pad/light was within reach.
2. Ensure Resident 3 ' s call light was answered promptly.
These deficient practices had the potential to result in the delay of care for Resident 1 and Resident 3.
Findings:
1. During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/2/2024 with diagnoses of acute (sudden onset) and chronic (continuing for a long time) respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body) with hypoxia (low levels of oxygen in the body tissues), end stage renal disease (irreversible kidney failure), pressure ulcer of sacral region (the triangular-shaped bone at the base of the back), stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and muscle wasting and atrophy (the loss of muscle mass and strength).
During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 10/8/2024, the MDS indicated Resident 1 was understood by others and had the ability to understand others. The MDS indicated Resident 1 needed some help (resident needed partial assistance from another person to complete any activities) with the upper and lower extremities. The MDS indicated Resident 1 was dependent (helper does all of the effort) on oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 1 was at risk of developing pressure ulcers/injuries.
During an observation on 12/4/2024 at 2:55 pm, Resident 1 ' s call pad/light was observed to be over the back of Resident 1 ' s bed/bed frame. Resident 1 stated the call pad/light should be on Resident 1 ' s chest close to the left arm since Resident 1 was only able to move the left arm.
2. During a review of Resident 3 ' s AR, the AR indicated the facility initially admitted Resident 3 on 3/31/2023 and recently admitted on [DATE] with diagnoses of cholelithiasis without obstruction (gallstones [hardened deposits of bile] are present in the gallbladder [organ that stores and releases bile] but are not causing any symptoms) and chronic kidney disease, stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of the blood).
During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 was understood by others and had the ability to understand others. The MDS indicated Resident 3 was dependent on toileting hygiene, lower body dressing, and putting on/taking off footwear.
During an observation on 12/5/2024 at 11:48 am, Resident 3 ' s call light was on. No staff was observed in the hallway near Resident 3 ' s room at the time. At 12:18 pm, housekeeping staff (unknown) was in front of Resident 3 ' s room and stated Resident 3 was waiting for a nurse. Resident 3 loudly verbalized Resident 3 was having pain on Resident 3 ' s side area. Resident 3 was then observed to scream nurse! Observed the hallway empty with no staff nearby. Observed the nurses ' station with no staff inside.
During an interview on 12/4/2024 at 2:55 pm, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 1 ' s call pad/light should be near Resident 1 to be able to call for a nurse when help was needed. LVN 3 stated anybody who on the floor was able to answer the call light.
During a review of the facility's P&P titled, Answering the Call Light, revised in October 2010, the P&P indicated the purpose of the procedure was to respond to the resident ' s requests and needs. The P&P indicated the general guidelines were when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Answer the resident ' s call light as soon as possible.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure:
1. Air purifiers were in working condition or...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure:
1. Air purifiers were in working condition or set to on.
2. Ventilation system was set to on and not on auto or off.
3. A Licensed Vocational Nurse (LVN 1) was wearing proper personal protective equipment (PPE- protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) while in a Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) room.
4. LVN 1 wore a N95 (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) mask properly while in the Red Zone (unit with Covid-19 confirmed positive residents).
5. Trash was emptied and not overflowing onto the floor in the Red Zone (designated a contaminated area used for isolation and the management of COVID-19 positive residents).
These deficient practices had the potential to cause the spread of Covid-19 infection to other residents and staff members in the facility during an active outbreak.
Findings:
During an interview on 12/4/2024 at 9:09 am with Public Health Physician (PHP), PHP stated the facility's ventilation system was not adequate. PHP stated the thermostats were set to auto or off. PHP stated the air purifiers were not plugged in. PHP stated the recommendations were sent last week and the facility was not following it. The PHP stated there were 40 residents in the Red Zone and that LVN 1 was not wearing PPE.
During an observation on 12/4/2024 at 9:12 am, LVN 1 was not wearing a yellow gown while standing in the doorway of a room in the Red Zone.
During an interview on 12/4/2024 on 9:21 am with the Infection Preventionist (IP), IP stated IP had a virtual tour with the PHP. IP stated PHP stated to ensure the thermostat was set to on and not auto. IP stated when PHP came in today, the thermostat was set to auto. IP stated PHP wanted the thermostat set to on so the air would be circulating for ventilation. IP stated the string hanging from the vents were not moving so it prompted PHP to look at the thermostat. IP stated PHP would like the facility to obtain more air purifiers, but they have not received them yet.
During a concurrent observation and interview on 12/4/2024 at 9:30 am with the IP, a yellow gown was on the floor next to an overfilled trash bin in the Red Zone. IP stated there was a designated housekeeper in the Covid-19 unit and the trash should not be overfilled.
During an observation tour on 12/4/2024 at 9:32 am with the IP, the following were observed:
a. Air purifier in between Station 5 and Station 6 (Red Zone) was not working.
b. The string hanging from Station 4 vent was not moving. IP went to the nearest thermostat and set it to on. IP stated, Now the string is moving.
c. LVN 1 was not properly wearing a N95 while in the Red Zone.
d. Air purifier in the hallway prior to entering the locked unit was not working.
During an interview on 12/4/2024 at 10:43 am with IP, IP stated PHP stated if there is poor ventilation, all of the germs could be stuck in one station or one room. IP stated there will not be clean ventilation. IP stated PHP stated they have found that facilities with poor ventilation have higher numbers during a Covid-19 outbreak. IP stated the same thing could happen if the air purifiers are not working or not on. IP stated PHP was not pleased with the amount of purifiers the facility had and wanted them to get additional air purifiers.
During an observation tour of the facility's Red Zone on 12/4/2024 at 4:19 pm with IP, the following were observed:
I. The vent in the center of the unit was set to auto.
II. The air purifier next to room [ROOM NUMBER] was not working properly.
III. The air purifier next to room [ROOM NUMBER] was turned off.
IV. A bedside table in front of a resident's room was wrapped with a PPE gown.
In front of the same room, two chairs had PPE gowns wrapped onto the chairs.
During an interview on 12/5/2024 at 10:24 am with housekeeping (HOUSE 1), HOUSE 1 observed the picture of the overfilled trash bin in Red Zone and stated it was not okay. HOUSE 1 stated the problem with an overfilled trash bin is more infection and that the trash should be emptied.
During an interview on 12/5/2024 at 2:09 pm with IP, IP stated LVN 1 was not wearing the N95 mask correctly. IP stated when IP made rounds in the Red Zone, the trash bin was overflowing again. IP stated the issue with the overflowing trash bins in the Red Zone is infection control and it should not be like that.
During an interview with the Environmental Supervisor (ES) on 12/5/2024 at 3:52 pm, ES stated the issue with the trash overflowing was infection control and nothing outside of the trash can should be on the floor. ES stated the facility staff's mask or gown should not be on the floor. ES stated whatever the facility staff places in the trash should not be on the floor.
During a review of the facility's policy and procedure (P&P), titled, Policies and Practices- Infection Control, revised on 07/2014, the P&P indicated, thefacility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The P&P indicated, the objectives of the facility's infection control policies and practices were to prevent, detect, investigate, and control infections in the facility.
During a review of the facility's P&P, titled, Coronavirus Disease (Covid-19)- Infection Prevention and Control Measures, revised 4/2020, the P&P indicated, the facility follows recommended standard and transmission-based precautions, environmental cleaning and social distancing practices to prevent the transmission of Covid-19 within the facility. The P&P indicated, while in the building, personnel are required to strictly adhere to established infection prevention and control policies, including appropriate use of PPE.
The P&P indicated, if there are Covid-19 cases in the facility, staff would wear all recommended PPE (i.e., gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based on availability).
During a review of the facility's Covid 19 Mitigation and Testing Plan (MATP), updated on 11/16/2024, the MATP indicated, all trash and dirty linen shall be bagged and placed in designated bins. The MATP indicated, it is the policy of the facility to protect their residents, staff and others who may be in their facility from harm during emergency events. The MATP indicated, to accomplish this, the facility has developed procedures for infection prevention and control to manage a COVID-19 outbreak. The MATP indicated, the guidance the infection preventionist will follow will be heavily influenced from the LHD (local health department), CDPH (California Department of Public Health), and the CDC (Centers for Disease Control and Prevention). The MATP indicated, the facility will ensure IP reviews guidance and recommendations provided by CDC, CDPH and/or LHD to maintain consistent situational awareness with highly evolving nature of COVID. The MTP indicated, the IP will monitor and collect all guidance from the LHD, CDPH, and CDC and educate all staff on best practices to ensure consistent application of safe IP practices.
During a review of the email sent from Public Health (PH) for recommendations to IP, dated 11/26/2024 and timed at 2:32 pm, PH recommendations indicated, to advise for fan to be on for all vents at all times. PH recommendations indicated, to have all air purifiers turned on in maximum setting.
Oct 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
Incontinence Care
(Tag F0690)
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 (Residents 4, 5, 6, and 7), w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four of five sampled residents (Residents 4, 5, 6, and 7), who were incontinent (lacking voluntary control over urination or defecation) of bowel and/or bladder, where promptly changed by facility staff after episodes of incontinence, in accordance with the facility's Policy and Procedure (P&P) on Call System and Urinary Continence and Incontinence -Assessment and Management .
This failure had the potential to result in skin breakdown and/or negatively affect the residents' dignity and quality of life for Residents 4, 5, 6, and 7.
Findings:
1. During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF, the heart doesn't pump enough blood as it should), bladder disorder, and fibromyalgia (a chronic condition that causes widespread pain and tenderness in the body).
During a review of Resident 4's Care Plan (CP) for Risk for Skin Breakdown dated 7/5/2024, the CP indicated Resident 4 was at risk for skin breakdown. The CP interventions included for staff to provide perineal (area between the anus and external genitals) care every shift and after each incontinence episode. The CP interventions included for staff to answer call lights promptly and to keep Resident 4 clean and dry.
During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/14/2024, the MDS indicated Resident 4 had no impairment in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 4 was dependent on staff for toileting, dressing, and bathing. The MDS indicated Resident 4 was always incontinent of bowel and bladder.
2. During a review of Resident 5's AR, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including respiratory failure (when the lungs can't get enough oxygen into the blood), heart failure (the heart cannot pump enough blood to all parts of the body) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar).
During a review of Resident 5's CP for Activities of Daily Living (ADL-a term used to describe the skills required to independently care for oneself) dated 4/29/2024, the CP indicated Resident had extensive ADL deficits related to toilet use. The CP interventions included for staff to keep Resident 5 clean and dry and to change as needed.
During a review of Resident 5's MDS, dated 8/5/2024, the MDS indicated Resident 5 was severely impaired (never/rarely made decisions) in cognitive skills. The MDS indicated Resident 5 required substantial/maximal assistance (helper does more than half the effort) from staff for toileting, dressing, and bathing. The MDS indicated Resident 5 was always incontinent of bowel and bladder.
3. During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including respiratory failure (when the lungs can't get enough oxygen into the blood) and heart disease with heart failure.
During a review of Resident 6's CP for ADL, updated 6/10/2024, the CP indicated Resident 5 had ADL deficits related to toilet use. The CP interventions included for staff to keep Resident 5 clean and dry and to change as needed.
During a review of Resident 6's MDS, dated 9/5/2024, the MDS indicated Resident 6 had no impairments in cognitive skills. The MDS indicated Resident 6 was dependent on staff for toileting, dressing, and bathing. The MDS indicated Resident 6 was always incontinent of bowel.
4. During a review of Resident 7's AR, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including respiratory failure and type 2 diabetes mellitus.
During a review of Resident 7's CP for Incontinence of Bowel and Bladder dated 2/17/2023, the CP indicated Resident 7 was always incontinent of bowel and bladder. The CP interventions included for staff to provide Resident 7 with incontinence care and change as needed and to answer Resident 7's call light promptly.
During a review of Resident 7's MDS, dated 7/24/2024, the MDS indicated, Resident 7 had no impairments in cognitive skills. The MDS indicated, Resident 7 required substantial/maximal assistance from staff for toileting and was dependent on staff for dressing and bathing. The MDS indicated Resident 7 was always incontinent of bowel and bladder.
During an interview on 10/23/2024 at 1:20 p.m. with Resident 4, Resident 4 stated sometimes Resident 4 had to wait 45 minutes to get help from staff to get changed after an episode of incontinence. Resident 4 stated having to wait that long made Resident 4 feel irritated.
During an interview on 10/23/2024 at 1:26 p.m. with Resident 5's wife (RP1), RP 1 stated sometimes Resident 5 went a long time without being changed after Resident 5 was incontinent of urine. RP 1 stated this would happen to Resident 5 during the evening time.
During an interview on 10/23/2024 at 1:50 p.m. with Resident 7, Resident 7 stated Resident 7 needed assistance from staff to change Resident 7's diaper after Resident 7's incontinence of bowel or bladder. Resident 7 stated sometimes Resident 7 waited longer than 15 minutes for staff to change Resident 7's diaper during the evening and nighttime shifts.
During an interview on 10/23/2024 at 2:06 p.m. with Resident 6's wife (RP 2), RP 2 stated RP 2 would visit Resident 6 at the facility often. RP 2 stated RP 2 had been present in the facility when Resident 6 had to wait one hour to get changed after bowel incontinence.
During an interview on 10/23/2024 at 3:43 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated residents (in general) assigned to CNA 1 occasionally had to wait up to 25 minutes for CNA 1 to change the residents after episodes of incontinence.
During an interview on 10/24/2024 at 1:15 p.m. with the Director of Nursing (DON), the DON stated facility staff (in general) needed to change incontinent residents within 15 minutes of being soiled. The DON stated residents would experience skin breakdown due to being left in soiled diapers for too long. The DON stated residents needed to be kept clean and dry to protect their dignity and quality of life.
During a review of the facility's P&P titled, Call System, Residents, dated September 2022, the P&P indicated Calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately.
During a review of the facility's P&P titled, Urinary Continence and Incontinence -Assessment and Management, dated August 2022, the P&P indicated The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.
Oct 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 a resident's right to be free from physical abuse (delibera...
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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 a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) as indicated in the facility's policies and procedures (P&P) titled, Abuse Prevention/Prohibition and Resident Rights for one of four sampled residents (Resident 1).
This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 and sustaining an acute fracture of the left nasal bone.
Findings:
1. During a review of Resident 1's admission Record (AR), AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) with late onset, dementia (a progressive state of decline in mental abilities) in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, fracture of nasal bones, and initial encounter for closed fracture (broken bone that does not break the skin).=
During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/3/2024, the MDS indicated, Resident 1 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated, Resident 1 was independent (completes the activity by themselves with no assistance from a helper) for eating, oral hygiene, and toileting hygiene. The MDS indicated, Resident 1 was independent for rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed).
During a review of Resident 1's Situation-Background-Assessment-Recommendation Communication Form (SBAR Communication Form) dated 10/3/2024, untimed, the SBAR Communication Form indicated on 10/3/2024, at 2 am, the Certified Nursing Assistant (CNA, unidentified) reported to Licensed Vocational Nurse (LVN) 5 that Resident 1's nose was bleeding. The SBAR Communication Form indicated LVN 5 noted Resident 1 with bleeding nose, cleaned Resident 1's nose area, and applied ice pack. The SBAR Communication Form indicated Resident 1 was unable to recall what happened. The SBAR Communication Form indicated staff initiated neurological checks (assesses level of consciousness, movement, hand grasp, pupil reaction, speech, and vital signs) and frequent visual monitoring of Resident 1.
During a review of Resident 1's Progress Notes (PN) dated 10/3/2024, timed at 3:52 am, the PN indicated Resident 1's on call physician (MD 1) ordered to transfer Resident 1 to General Acute Care Hospital (GACH) 1 for further evaluation.
During a review of Resident 1's GACH 1 Emergency Department (Notes (ED Notes), dated 10/3/2024, timed at 7:32 am, the ED Notes indicated, Resident 1 came from Skilled Nursing Facility (SNF) 1 and was hit on the face by another resident (Resident 2). The ED note indicated Resident 1 had an abrasion on Resident 1's chin.
During a review of Resident 1's Computed Tomography Scan (CT Scan- a medical imaging technique used to obtain detailed internal images of the body used to diagnose disease or injury), dated 10/3/2024, timed at 8:17 am, the CT Scan indicated Resident 1 had nasal soft tissue swelling and an acute fracture (the result of a traumatic injury that causes a clean and immediate break in the bone) of the left nasal bone without significant displacement (a broken bone where the pieces of bone remain aligned).
During a review of Resident 1's GACH 1 ED Notes, dated 10/3/2024, timed at 2:24 pm, the ED Notes indicated Resident 1 had no other complaints or findings on exam. The ED Notes indicated Resident 1 did not require further intervention and was stable for discharge back to SNF 1.
2. During a review of Resident 2's AR, AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control) and poor wound healing with hyperglycemia (elevated blood sugar), paranoid personality disorder (PPD- a mental condition in which a person has a long-term pattern of distrust and suspicion of others) and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological (the body and its systems) condition, delusional (having false or unrealistic beliefs) disorders, schizoaffective (a mental illness that can affect thoughts, mood, and behavior) disorder, unspecified.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated, Resident 2 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated, Resident 2 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated, Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for rolling left and right.
During a review of Resident 2's SBAR Communication Form dated 10/3/2024, untimed, the SBAR Communication Form indicated on 10/3/2024, at 2 am, Resident 2 was involved in a physical altercation with another resident (Resident 1). The SBAR Communication Form indicated Resident 2 stated Resident 2's roommate (Resident 1) was standing too close to him (Resident 2), and Resident 2 felt his roommate (Resident 1) was going to hit him (Resident 2). The SBAR Communication Form indicated Resident 2 struck Resident 1 in the nose. The SBAR Communication Form indicated Resident 1 and Resident 2 were immediately separated and staff initiated frequent visual monitoring of Resident 2.
During a telephone interview on 10/10/2024 at 3 PM with LVN 5 , LVN 5 stated Resident 1 came out of Resident 1's room with a bloody nose. LVN 5 stated Resident 1 and Resident 2 were roommates. LVN 5 stated Resident 2 stated Resident 2 struck Resident 1 in the face. LVN 5 stated Resident 2 stated Resident 2 did that because Resident 1 was standing too close to Resident 2. LVN 5 stated Resident 2 thought Resident 1 was going to hit Resident 2.
During a telephone interview on 10/10/2024 at 3:44 PM with Registered Nurse (RN) 1, RN 1 stated LVN 5 informed RN 1 that Resident 1's nose was bleeding. RN 1 stated RN 1 asked Resident 2 what happened. RN 1 stated Resident 2 stated Resident 1 was too close to Resident 2. RN 1 stated Resident 2 stated Resident 2 hit Resident 1 in the face and with Resident 2's fist.
During an interview on 10/10/2024 at 4:50 PM with the Administrator (ADM), the ADM stated that residents were supposed to be free from abuse. The ADM stated residents must feel safe mentally, physically, and emotionally. The ADM stated the facility staff were there to serve the residents. The ADM stated the facility staff needed to make sure the residents were safe in every aspect. The ADM stated a physical altercation occurred between Resident 1 and Resident 2. The ADM stated to prevent a physical altercation between residents, the facility staff must make sure the roommates were compatible and to make sure there was enough close supervision. The ADM stated facility staff needed to be trained to identify certain behaviors so they could prevent an altercation from happening. The ADM stated the facility staff did their best.
During a review of the facility's P&P titled, Abuse Prevention/Prohibition, revised November 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 systems to promote an environment free from abuse and mistreatment.
During a review of the facility's P&P titled, Resident Rights, revised February 2021, the P&P indicated, federal and state laws guarantee basic rights to all residents of this facility. The policy indicated these rights included the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation.
Aug 2024
27 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the window screen in a resident's room was inta...
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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 window screen in a resident's room was intact for one of one sampled resident (Resident 121).
This deficient practice had the potential to affect the residents' right to a safe, clean, comfortable, and homelike environment and put the resident at risk for physical discomfort.
Findings:
During a review of Resident 121's admission Record (AR) the AR indicated Resident 64 was readmitted to the facility on [DATE] with diagnoses that included unspecified open wound of the right and left buttocks.
During a review of Resident 121's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 8/19/2024, the MDS indicated Resident 121 was cognitively intact (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required partial/moderate assistance (helper does less than half effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.) to change positions in bed and move from sitting to standing position.
During a concurrent observation and interview on 8/27/2024 at 10:40 am with Resident 121 in Resident 121's room, the window screen had a hole in the bottom right corner and the window had a sign posted to keep the window closed. Resident 121 stated, there was a hole in the window screen and had requested the maintenance worker (PMW) and Administrator (ADM) to fix it about a month and a half ago, but it was not repaired. Resident 121 further stated, she requested a sign be put on the window asking staff not to open it because she did not want bugs to come in the room through the hole.
During a concurrent observation and interview on 8/27/24 10:48 am with Licensed Vocational Nurse 9 (LVN 9) in Resident 121's room, the window screen had a hole in the bottom right corner. LVN 9 stated, she would inform the maintenance staff to have it repaired. LVN 9 further stated, flies and insects could get inside the room through the window screen hole and that would be harmful to the resident.
During a concurrent observation and interview on 8/27/24 10:48 am with Maintenance Supervisor (MS) in Resident 121's room, the window screen had a hole in the bottom right corner. MS acknowledged the broken window screen and stated, PMW did not inform MS of the issue and MS did not have a record of a work order to fix the broken screen. MS stated, the broken window screen would allow insects to get in the room, but because the air conditioning was frequently on it was unnecessary for the residents to open their window.
During a review of the facility's Policy and Procedure (P&P) titled, Maintenance Service, revised December 2009, the P&P indicated maintenance services should be provided to all areas of the building, grounds, and equipment. The P&P indicated, the Maintenance Department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times and were responsible for maintaining the building in compliance with federal, state, and local laws, regulations, and guidelines. The P&P indicated, the Maintenance Department was responsible for maintaining the building in good repair, free from hazards, and maintenance personnel should follow established safety regulations to ensure the safety and well-being of all concerned.
During a review of the facility's P&P titled, Homelike Environment, revised February 2021, the P&P indicated, residents were provided with a safe, clean, comfortable, and homelike environment and staff provide person-centered care that emphasized the resident's comfort, independence and personal needs and preferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to develop an individualized/person- centered care plan for one of one sampled resident (Resident 66) on bilateral hand mittens in accordance w...
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Based on interview and record review the facility failed to develop an individualized/person- centered care plan for one of one sampled resident (Resident 66) on bilateral hand mittens in accordance with the facility's Policy and Procedure (P&P) titled Care Plans - Comprehensive.
This deficient practice had the potential for Resident 66 to not receive appropriate care treatment and/or services specific to the resident's needs.
Findings:
During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted Resident 66 on 12/19/2023 with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time) and encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing).
During a review of Resident 66's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/21/2024, the MDS indicated, Resident 66 's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 66 was dependent (full staff performance) with oral hygiene, toileting hygiene, shower, lower body dressing, putting on/taking off footwear and personal hygiene.
During a review of Resident 66's Physician Order (PO) dated 7/7/2024, the PO indicated for nursing staff to apply bilateral hand mittens to prevent patient (resident) from pulling essential tubing every shift.
During a review of Resident 66's History and Physical (H&P) dated 8/23/2024, the H&P indicated Resident 66 did not have the capacity to understand and make decisions.
During a concurrent interview and record review on 8/29/2024 at 9:40 am with Licensed Vocational Nurse 3 (LVN 3) and RN Supervisor (RN Sup), Resident 66's medical record was reviewed. LVN 3 stated there was no other clinical documentation that a care plan was developed for Resident 66 to address the resident's use of hand mittens. RN Sup stated, a care plan needed to be developed and implemented for the management of Resident 66's use of mittens in order for Resident 66 to receive proper care and effective interventions from the nursing staff.
During a review of the facility's undated P&P titled, Care Plans - Comprehensive, revised 9/2010, the P&P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological need is developed for each resident. The P&P indicated the care planning/Interdisciplinary team is responsible for the review and updating of care plan when there has been a significant change in the resident's condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 124) had...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 124) had padded siderails as a seizure precaution, as ordered.
This deficient practice had the potential to cause injury to Resident 124 during a seizure (abnormal movements or behavior due to unusual electrical activity in the brain) episode.
Findings:
During a review of Resident 124's admission Record (AR), the AR indicated Resident 124 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy (disease of the brain that alters brain function or structure) and unspecified, intractable (uncontrolled by two or more medications) epilepsy (a chronic brain disorder that causes seizures).
During a review of Resident 124's History and Physical (H&P), dated 2/26/2024, the H&P indicated Resident 124 did not have the capacity to understand and make decisions.
During a review of Resident 124's untitled Care Plan (CP), dated 2/27/2024, the CP indicated Resident 124 was at risk for injury and ineffective breathing patterns related to altered state and consciousness due to seizure activity. The CP approaches/plan indicated Resident 124 will have padded side rails on Resident 124's bed.
During a review of Resident 124's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 8/13/2024, the MDS indicated Resident 124 was rarely or never understood, was dependent (helper does all of the effort and resident does none of the effort to complete the activity) for all self-care activities (oral, toileting and personal hygiene, dressing).
During a review of Resident 124's Order Summary Report (OSR) dated 8/29/2024, the OSR indicated an order for Resident 124 to have half bilateral (right and left side) padded siderails at all times for seizure precautions, ordered on 7/4/2024.
During a review of Resident 124's OSR dated 8/29/2024, the OSR indicated the following active orders for Resident 124:
1. Levetiracetam (medication to treat epilepsy/seizures) Oral Solution 100 milligrams (mg)/milliliters (ml) - Give 10 ml via Gastrostomy Tube (G-tube- surgical insertion of a tube, creating an artificial external opening into the stomach for nutritional support) two times a day for seizures.
2. Valproic Acid (medication to treat seizures) Oral Solution 250 mg/5 ml (Valproate Sodium) - Give 5ml via G-tube three times a day for seizures.
During an observation on 8/27/2024 at 3:30 pm in Resident 124's room, Resident 124 was asleep in bed with a tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing) connected to a ventilator (machine that supports breathing). The bedrails at each side of the bed were unpadded.
During a concurrent observation and interview on 8/27/2024 at 3:48 pm with Registered Nurse 7 (RN 7), in Resident 124's room, Resident 124's bed had unpadded bedrails on both sides. RN 7 stated Resident 124's bed rails were not padded and should have been padded to protect Resident 124 from hitting his head during a seizure.
During a review of the facility's Policy and Procedure (P&P) titled, Accommodation of Needs, revised March 2021, the P&P indicated the facility's environment and staff behaviors were directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being and included accommodating the resident's need for adaptive devices and modifications to the physical environment on an ongoing basis.
During a review of the facility's P&P titled, Seizures and Epilepsy - Clinical Protocol, revised November 2018, the P&P indicated staff and physician will monitor the progress of individuals with a new seizure of a seizure disorder and will modify interventions accordingly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide appropriate care to prevent Urinary tract Infection ([UTI] an infection in any part of the urinary system [kidneys, bl...
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Based on observation, interview and record review, the facility failed to provide appropriate care to prevent Urinary tract Infection ([UTI] an infection in any part of the urinary system [kidneys, bladders, ureters and urethral]) for one of two sampled residents (Resident 192) who was on Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) by failing to ensure:
Licensed staff monitor Residents 192's urine output and notify the physician promptly for signs and symptoms of UTI.
This deficient practice placed Resident 192 at risk for delayed treatment and worsening of infection.
Findings:
During a review of Resident 192's admission Record (AR), the AR indicated the facility admitted the resident on 6/21/24, with diagnoses that included hypertension (high blood pressure) and epilepsy (a brain disorder that causes recurring, unprovoked seizures).
During a review of Resident 192's Physician Order Sheet (POS) dated 6/23/24, the POS indicated an order for Foley catheter attached to bedside drainage bag for diagnosis of neurogenic bladder (a person lacks bladder control due to brain, spinal cord, or nerve problems). The POS also indicated to monitor Resident 192 for signs and symptoms of UTI every shift until 9/5/24.
During a review of Resident 192's Care Plan (CP) for the use of Foley catheter dated 6/23/24, the CP indicated for nursing staff to observe Resident 192's urine output for signs of UTI (dark urine color, sediments, foul odor) and to immediately notify the physician.
During observations on 8/27/24 at 10:41 a.m. and 3:31 p.m., Resident 192 was lying on his back in bed, awake and non-communicative. Resident 192's Foley catheter was connected to a urine bag that contained slightly cloudy yellow urine output with moderate amount of urine sediments in the catheter tubing.
During a concurrent observation and interview on 8/28/24 at 1:50 p.m., Resident 192's Foley catheter tubing had slightly cloudy yellow urine with moderate amount of urine sediments and small blood clots. Licensed Vocational Nurse 5 (LVN 5) also observed Resident 192's urine output while in the resident's room. LVN 5 stated she did not use a flashlight to see better if there were sediments in Resident 192's catheter tubing when she checked the urine output on 8/28/24 at around 9 a.m.
During an interview on 8/28/24 at 2 p.m., Certified Nursing Assistant 5 (CNA 5) stated she emptied the urine collection bag of Resident 192 without checking the Foley catheter tubing for presence of urine sediments because the catheter tubing was covered with Resident 192's blanket.
During a concurrent interview and record review on 8/28/24 at 2:08 p.m., LVN 5 stated there was no documented evidence licensed staff monitored Resident 192's urine output and the physician was made aware of urine sediments in the foley catheter tubing since 8/27/24. LVN 5 stated physician need to be notified as soon as signs of UTI was observed to prevent delay of treatment and worsening of infection.
During a review of the facility's policy and procedures (P&P) titled, Catheter Care, Urinary dated 8/2022, the P&P indicated licensed staff to immediately notify the physician if the resident had signs and symptoms of UTI.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 205) who was fed by enteral means received appropriate treatment and services b...
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Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 205) who was fed by enteral means received appropriate treatment and services by failing to elevate the head of the bed while the resident was receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) and failing to ensure the GT flush was connected to Resident 205 in accordance with the resident's care plan and the facility's Policy and Procedure (P&P) titled Enteral Feedings - Safety Precaution.
This deficient practice had the potential to cause aspiration (inhalation of foreign materials) and lead to other adverse consequences for the resident.
Findings:
During a review of Resident 205's admission Record (AR), the AR indicated the facility admitted Resident 205 on 7/19/2024 with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support) and encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing).
During a review of Resident 205's Care Plan (CP) titled Oral Care Aspiration-Related to Pneumonia (infection that inflames the lung) Reduction/Prevention initiated on 7/19/2024, the CP indicated Resident 205 was at risk for aspiration related to pneumonia secondary to supine (lying face upward) position. The CP interventions included for the nursing staff to elevate Resident 205's head of bed, no supine unless specifically indicated.
During a review of Resident 205's History and Physical (H&P) dated 7/20/2024, the H&P indicated Resident 205 did not have the capacity to understand and make decisions.
During a review of Resident 205's CP titled Nutrition Care Plan: Feeding Tubes initiated on 7/20/2024, the CP indicated Resident 205 was at risk for altered Nutrition/Hydration (process of replacing water/fluids in the body) related to dysphagia (difficulty swallowing) and GT. The care plan interventions indicated for nursing staff to administer tube feeding to Resident 205 as ordered.
During a review of Resident 205's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/25/2024, the MDS indicated Resident 205's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 205 was dependent (full staff performance) with oral hygiene, toileting hygiene, shower, lower body dressing, putting on/taking off footwear and personal hygiene.
During a review of Resident 205's Order Summary Report (OSR) dated 7/31/2024, the OSR indicated for staff to elevate Resident 205's head of bed up at 30 to 45 degrees every shift.
During a review of Resident 205's OSR dated 8/16/2024, the OSR indicated for licensed staff to flush GT with 60 millimeters (ml, unit of measurement) of water for 20 hours to provide 1,200 ml per day.
During a concurrent observation in Resident 205's room and interview on 8/27/2024 at 11:09 am with Licensed Vocational Nurse 1 (LVN 1), Resident 205 was asleep in supine position with the head of the bed not elevated to 30 to 45 degrees. Resident 205 was connected to a GT formula that was infusing (on). Resident 205's water flush tubing was hanging and not connected to Resident 205 with remaining amount of 500 ml. LVN 1 stated, the water flush needed to be connected continuously as per doctor's order to prevent dehydration.
During a concurrent observation of Resident 205 in Resident 205's room and interview with LVN 1 on 8/27/2024 at 11:10 am, LVN 1 stated, Resident 205 was almost flat in bed and Resident 205 would possibly aspirate. LVN 1 stated, Resident 205's head of bed needed to be elevated to 30 degrees.
During a concurrent interview and record review on 8/27/2024 at 11:21 am with Registered Nurse 2 (RN 2) of Resident 205's medical records, RN 2 stated Resident 205's head of bed needed to be elevated to 30 to 45 degrees while receiving GT feeding for aspiration precaution. RN 2 stated, water flush tubing needed to be connected to Resident 205 to prevent dehydration.
During a review of the facility's P&P titled, Enteral Feedings - Safety Precaution, revised 11/2018, the P&P indicated feeding pumps must be calibrated periodically to ensure that the pump delivers the prescribed volume within 10 percent accuracy. The P&P indicated to prevent aspiration elevate the head of bed at least 30 degrees during tube feeding and at least 1 hour after feeding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsi...
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Based on observation, interview and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily and was not posted in a prominent location readily accessible to residents and visitors for viewing in accordance with the facility's Policy and Procedure (P&P) titled Posting Direct Care Daily Staffing Numbers for three of three days ( 8/26/2024, 8/28/2024 and 8/29/2024).
This deficient practice of posting inaccurate nurse staffing information would mislead the residents and visitors of the actual staffing in the facility that may affect the quality of nursing care provided to the residents.
Findings:
During a concurrent interview on 8/29/2024 at 10:09 am with the Assistant Director of Staff and Development (ADSD) and record review of the nurse staffing information and the actual staffing sign in sheet for the staff who worked in the facility, the ADSD stated ADSD missed to post the nurse staffing information on 8/26/2024 in the Sub Acute Unit.
During a concurrent interview and record review on 8/29/2024 at 10:41 am with the Director of Staff Development (DSD), the nurse staffing information, and the actual staffing sign in sheet for the staff who worked in the facility were reviewed and indicated the following:
1. On 8/28/2024 for the 3 pm to 11 pm shift, there were seven Certified Nurse Assistant (CNA) posted on the nursing staffing posting while the sign in sheet indicated six CNA worked for the 3 pm to 11 pm shift on 8/28/2024 in the Sub Acute Unit.
2. On 8/29/2024 for the 11 pm to 7 am shift, there were six Licensed Vocational Nurse (LVN) on the nursing staffing posting while the sign in sheet indicated four LVN's worked for the night 11 pm to 7 am shift on 8/29/2024 in Skilled Nursing Facility
During an interview on 8/29/2024 at 10:41 am with the DSD, the DSD stated it was important that the nursing staffing information posted was correct, accurate and visible to the staff and visitors to ensure the facility met the staffing requirement to provide patient care. The DSD stated, the staffing information needed to be updated to reflect the actual number of staff working on a specific day.
During a review of facility's P&P titled, Posting Direct Care Daily Staffing Numbers, revised 7/2016, the P&P indicated, the facility will post on daily basis for each shift the number of nursing personnel responsible for providing direct care to residents. The P&P indicated within 2 hours of the beginning of the shift, the number of Licensed Nurses (RN's, LPNs, and LVN's) and the number of unlicensed nursing personnel (CNA's) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain an informed consent when the physician ordered ...
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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 obtain an informed consent when the physician ordered psychotropic medication (any drug that affects behavior, mood, thoughts, or perception), buspirone (an antipsychotic medicine, it works by changing the actions of chemicals in the brain) for one of five sampled residents (Resident 210).
This failure had the potential risk to place the resident at risk for unnecessary psychotropic medications.
Findings:
During a review of Resident 210's admission Record (AR), the AR indicated Resident 18 was readmitted to the facility on [DATE].
During a review of Resident 210's Order Summary Report (OSR), the OSR indicated an order on 7/22/2024 for licensed staff to administer to Resident 210 buspirone oral tablet 5 milligrams (mg- unit of measurement), 0.5 tablet by mouth two times a day for anxiety.
During a review of Resident 210's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 7/28/2024, the MDS indicated Resident 210 had clear speech, usually understood others, and made self-understood. Resident 210 required substantial/maximal assistance (helper does more than half the effort) for personal hygiene, upper body dressing, and rolling left and right. Resident 210 had active diagnoses including dementia (loss ability to think, remember and reason) and anxiety (a feeling of fear, dread, or uneasiness).
During a review of Resident 210's Informed Consent for buspirone use, the consent did not have the signature of the resident or resident's responsible party and physician's signature, and the consent was not dated.
During an interview on 8/29/2024 at 11:51 am, Licensed Vocational Nurse 8 (LVN 8) stated, all psychotropic medication required a consent from the resident before administration so that the resident or resident's responsible party understood the reason of use, its benefits and risks, and possible side effects.
During an interview on 8/29/2024 at 3:17 pm, Registered Nurse 5 (RN 5) stated, RN 5 was responsible for working with the physician for psychotropic medication. RN 5 stated, there was no informed consent signed for Resident 210 for buspirone use. RN 5 stated, RN 5 missed Resident 210's consent. RN 5 stated, the facility should obtain consent for psychotropic medication use, so the resident or responsible party would know the indication of use, risks and benefit, and possible side effects.
During a review of the facility's policy and procedure titled Psychoactive Medication Informed Consent, released 3/2024, indicated Before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident and obtain informed written consent signed by the resident or the resident's representative along with, the signature of the health care professional declaring the required material information has been provided.
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 to offer preferences regarding food choices for one of on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to offer preferences regarding food choices for one of one sampled resident (Resident 8).
This deficient practice had the potential to result in insufficient meal intake and potentially result to weight loss for Resident 8.
Findings:
During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide from the lungs).
During a review of Resident 8's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 6/18/2024, the MDS indicated Resident 8 was cognitively intact (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and Resident 8 thought it was somewhat important to have snacks available between meals.
During an interview on 8/27/2024 at 10:12 am with Resident 8 in Resident 8's room, Resident 8 stated Resident 8 received the same food over and over - cottage cheese, apple sauce, mashed potatoes three times a day and had no variety for meals. Resident 8 appeared upset and stated Resident 8 was tired of it and the only thing I look forward to was coffee.
During a lunch observation on 8/27/2024 at 1:34 pm in Resident 8's room, Resident 8's meal tray consisted of mashed potatoes with gravy on a plate, a cup of yogurt, a cup of cottage cheese, a cup of chocolate pudding, apple sauce and thickened liquids of juice and water.
During a review of Resident 8's Order Summary Report (OSR), the OSR indicated a diet order dated 8/28/2024 for a consistent carbohydrate diet (a diet with the same amount of carbohydrates used to help people with diabetes manage their blood sugar levels) with no added salt diet, soft texture, nectar/mildly thick consistency, ground, with pureed (smooth, creamy texture) meat, no straw (aspiration precaution -measures taken to prevent food or liquid from going into the lungs).
During an interview on 8/28/2024 at 9:00 am with Resident 8 in Resident 8's room, Resident 8 stated she had yogurt, cereal, cottage cheese, and applesauce for breakfast.
During a lunch observation on 8/28/2024 at 1:22 pm in Resident 8's room, Resident 8's meal tray consisted of mashed potatoes with gravy and pureed chicken on a plate, a cup of yogurt, cottage cheese, applesauce, and nectar thickened liquids of punch and water.
During a concurrent interview and record review on 8/28/2024 at 1:22pm with Resident 8, Resident 8's lunch meal ticket dated 8/28/2024 was reviewed. The lunch meal ticket indicated, Resident 8's dislikes were soup, spinach, corn, peas, milk, vanilla yogurt, beef, chicken, turkey, milk soup, and rice. Resident 8 stated, she did not dislike beef nor turkey.
During an interview on 8/28/2024 at 1:47 pm with the Dietary Service Manager (DSM), DSM stated Resident 8 received the same food everyday - mashed potatoes, gravy, cottage cheese, apple sauce, chocolate pudding.
During an interview on 8/29/2024 at 12:54 pm with Resident 8, Resident 8 stated she got the same meals daily and would receive for:
Breakfast - cottage cheese, applesauce, yogurt, and cereal to mix together, and coffee.
Lunch & Dinner - mashed potatoes with gravy, occasionally with a pureed meat, applesauce, cottage cheese, chocolate pudding, a cup of yogurt, and coffee.
Snack - applesauce (Resident 8 stated she would refuse)
Resident 8 stated, she complained a long time ago to staff about the lack of variety and did not want to eat the same thing every day for 20 years. Resident 8 stated, she was told by staff that the diet order needed to be followed. Resident 8 further stated, food preferences were not assessed before, but was seen by the DSM yesterday.
During a lunch observation on 8/29/2024 at 1:55 pm in Resident 8's room, Resident 8's meal tray consisted of mashed potatoes with gravy, pureed meat, applesauce, cottage cheese, yogurt and two thickened drinks.
During an interview on 8/30/2024 at 11:24 am with the DSM, DSM stated past food preferences would be updated on the meal ticket and DSM would look for past preferences documented in the previous electronic charting system (AHT - inaccessible to surveyors) that was used.
During a concurrent interview and record review on 8/30/2024 at 12:47 pm with Minimum Data Set Nurse (MDSN), Resident 8's Quarterly Nutritional Screening, dated 4/5/2023 was reviewed. The Quarterly Nutritional Screening indicated, no change updated for food preference likes and food preference dislikes and was completed by DSM. MDSN stated, it was the last nutritional screening and dietary preferences found in the previous electronic charting system.
During a review of the facility's Policy and Procedure (P&P) titled, Resident Food Preferences, revised July 2017, the P&P indicated, when possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. The P&P further indicated, the food services department would offer a variety of foods at each scheduled meal, as well as access to nourishing snacks thought the day and night.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0839
(Tag F0839)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 10 Restorative Nursing Aides (RNA, cert...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 10 Restorative Nursing Aides (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) did not perform job duties out of the State certification, including managing feeding through a gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding) for one of four sampled residents (Resident 109) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move).
This failure had the potential for Resident 109 to have complications related to the G-tube.
Findings:
During a review of Resident 109's admission Record (AR), the AR indicated the facility admitted Resident 109 on 3/20/2024 and re-admitted on [DATE]. The AR indicated Resident 109's diagnoses included parkinsonism (group of conditions with symptoms including slow movements, stiffness, tremors, and balance issues), dementia (decline in mental ability severe enough to interfere with daily life), dysphagia (difficulty swallowing), attention to tracheostomy (surgical opening made through the front of the neck and into the windpipe [trachea] to allow air into the lungs), dependence on a ventilator (machine that mechanically assists with breathing) and attention to gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding).
During a review of Resident 109's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 6/20/2024, the MDS indicated Resident 109 had severely impaired cognition (ability to think, understand, learn, and remember), impaired ROM to both arms and legs, and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for oral hygiene, toileting, dressing, and rolling to both sides in bed.
During a review of Resident 109's Physician Orders (PO), dated 6/22/2024, the PO indicated to provide continuous water flush at 50 cubic centimeters (measure of volume) per hour for 20 hours. Another PO dated 8/7/2024, indicated to provide Jevity 1.2 (specific type of G-tube feeding) through the enteral (within digestive system) pump (G-tube feeding machine) at 55 milliliters (ml-measure of volume) per hour for 20 hours.
During a concurrent observation and interview on 8/28/2024 at 9:25 a.m. in Resident 109's bedroom, Resident 109's RNA session was observed. Resident 109 was lying in bed while Restorative Nurse Aide 4 (RNA 4) adjusted Resident 109's bed into a flat position. Resident 109's feeding machine was turned off. RNA 4 stated the first thing RNA 4 does prior to performing ROM exercises was turning off Resident 109's feeding machine to prevent aspiration (when food or liquid goes into the airway). RNA 4 elevated Resident 109's head-of-bed after performing ROM exercises and then turned on the G-tube feeding machine.
During an interview on 8/28/2024 at 9:37 a.m. with RNA 4, RNA 4 stated she turned off Resident 109's G-tube feeding machine before every RNA session and turned on the feeding machine at the end of the session after elevating Resident 109's head-of-bed.
During an interview on 8/28/2024 at 10:49 a.m. with Registered Nurse 3 (RN 3), RN 3 stated the Licensed Vocational Nurse (LVN) and the Registered Nurse (RN) were the only facility staff allowed to turn on and turn off the G-tube feeding machine because the machine was administrating tube feeding into the resident's body. RN 3 stated Certified Nursing Assistants (CNAs) and RNAs were not allowed to turn on and turn off the G-tube feeding because it was not in their scope of practice (range of actions, processes, and procedures that a licensed health professional is allowed to perform) and for the resident's safety.
During an interview on 8/28/2024 at 11:46 a.m. with the Lead Restorative Nurse Aide (RNA 1), RNA 1 stated RNAs were not allowed to turn on and off G-tube feeding. RNA 1 stated RNAs were supposed to call the licensed nurse to turn off the G-tube machine.
During an interview on 8/28/2024 at 12:02 p.m. with RNA 4, RNA 4 stated she should have called the licensed nurse to turn on and turn off Resident 109's G-tube feeding.
During a review of the facility's Policy and Procedure (P&P) titled, Enteral Feedings - Safety Precautions, revised 11/2018, the P&P indicated all personnel responsible for preparing, storing, and administering enteral nutrition formulas will be trained, qualified, and competent in their responsibilities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
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 explain the Agreement To Arbitrate Disputes Related To Medical Malp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to explain the Agreement To Arbitrate Disputes Related To Medical Malpractice Binding Arbitration Agreement (AA, Binding Arbitration Agreement), signed 8/12/2024, for one of three sampled residents (Resident 522), in a language Resident 522 understood when agreement was entered for binding arbitration (involves the submission of a dispute to a neutral party who hears the case and makes a decision).
This failure had the potential to result in Resident 522 to not be able to make an informed decision and/or his rights to be denied.
Findings:
During a review of the Resident 522's admission Record (AR), the AR indicated Resident 522 was admitted on [DATE].
During a review of Resident 522's History and Physical (H&P) dated 8/13/2024, the H&P indicated Resident 522 was admitted to the facility for uterine cancer (cancer of the uterus) and hypertension (increased blood pressure). The H&P indicated Resident 522 had the capacity to make decisions.
During a review of Resident 522's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 8/16/2024, the MDS indicated Resident 522's language preference was Spanish. Resident 522 had clear speech, had the ability to understand others and made self-understood. Resident 522 required substantial/maximal assistance (helper does more than half the effort) for personal hygiene, upper body dressing, and rolling left and right.
During an interview through the facility's translation services hotline, on 8/30/2024 at 11:05 am, regarding Resident 522's signed AA, Resident 522 stated Resident 522 did not speak English and did not understand Resident 522's AA in English version. Resident 522 stated, Resident 522 was not explained and did not understand the contents of the AA that Resident 522 signed. Resident 522 stated, Resident 522 signed the AA together with other admission paperwork.
During an interview with admission Director (AD) on 8/30/2024 at 11:36 am, the AD stated, Resident 522 spoke Spanish, the facility should explain AA in Spanish and provide the AA in Spanish version for Resident 522 to read, understand and sign. The AD stated, the facility should provide AA to its resident or their responsible party in a language that they understood. The AD stated, it was a resident's right that they fully understood what an AA was and agreed to enter AA.
During a review of the facility's Policy and Procedure (P&P) titled Arbitration Agreement, released 7/2022, the P&P indicated, The agreement must be explained in a form a manner that allows a resident or his or her representative understand the contract.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for two of 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 provide reasonable accommodation of needs for two of two sampled residents (Residents 107 and 181) by failing to ensure the residents' call light were within reach and appropriate to the resident's physical ability.
These deficient practices had the potential for residents not to receive necessary care or received delayed services to meet their needs.
Findings:
a. During a review of Resident 107's admission Records (AR), the AR indicated Resident 107 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anoxic brain damage (occurs when the brain is deprived of oxygen) and chronic kidney disease (a long-term condition where the kidneys do not work as well as they should).
During a review of Resident 107's Care Plan (CP) dated 2/6/2023, the CP indicated Resident 107 had deficit in Activities of Daily Living (ADL) related to quadriplegia (paralysis that affects all a person's limbs and body from the neck down), visual impairment, bladder incontinence (inability to hold urine), and at risk for fall. The CP interventions included for staff to provide call light within reach and staff to answer the call light promptly.
During a review of Resident 107's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 7/12/2024, the MDS indicated Resident 107 had severely impaired cognition (ability to understand) and required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, maximal assistance (helper did more than half of the effort) with upper and lower body dressing and totally dependent (helper did all of the effort to complete the activity) with toileting hygiene, shower, and personal hygiene.
During a concurrent observation and interview on 8/27/2024 at 10:46 am Certified Nursing Assistant 2 (CNA 2) inside Resident 130's room, Resident 130 was in bed on her back with call light on the floor. Resident 107 stated, I did not know where my call light was. CNA 2 stated Resident 107's call light was on the floor. CNA 2 stated the call light should be placed close and next to Resident 107 so the resident could call whenever she needed assistance and during emergency.
During an interview on 8/28/2024 at 4:26 pm with the director of nursing (DON), the DON stated call light should be clipped on the bed, or the resident's clothes where the resident could reach and had easy access to it so the resident could call for help and staff able to assists the resident's needs in a timely manner.
During a review of the facility's policy and procedure (P&) titled, Call System, Resident, dated September 2022, the P&P indicated, Each resident was provided with a means to call staff directly for assistance from his/her bed, from toileting /bathing facilities and from the floor.
b. During a review of Resident 181's AR, the AR indicated the facility admitted Resident 181 on 7/24/2024 with diagnoses including malignant neoplasm (cancer, abnormal cell growth) of the thyroid gland (makes and releases hormones to the body), traumatic (sudden physical injury) subdural hemorrhage (bleeding in the brain), hemiplegia (weakness or difficulty to move one side of the body) affecting the right dominant side (more often used during completion of daily living tasks), history of falling, and epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking).
During a review of Resident 181's Care Plan (CP) for activities of daily living (ADL) dated 7/25/2024, the CP indicated Resident 181 required assistance for personal hygiene, bed mobility, dressing, toileting, bathing, and transfers. The CP interventions included to have Resident 181's call light within reach with prompt staff response and to focus on Resident 181's abilities.
During a review of Resident 181's MDS, dated [DATE], the MDS indicated Resident 181 had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 181 required partial/moderate assistance (helper does less than half the effort) for eating and oral hygiene, substantial/maximal assistance (helper does more than half the effort) for lower body dressing, rolling to both sides in bed, transfers to the side of the bed, sit to stand, and chair/bed-to-chair transfers, and dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for toileting and upper body dressing.
During a review of Resident 181's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Initial Evaluation, dated 8/25/2024, the OT Evaluation indicated Resident 181 had ROM within functional limits ([WFL] sufficient movement without significant limitation) in both arms, decreased strength in both arms, and impaired coordination in both arms.
During a concurrent observation and interview on 8/27/2024 at 11:29 a.m. in Resident 181's bedroom, Resident 181 was lying in bed awake with the call light on the floor. Resident 181 stated Resident 181 was unable to reach the call light. Licensed Vocational Nurse 3 (LVN 3) stated Resident 181's call light should be within reach to call staff for assistance. LVN 3 stated Resident 181 could fall trying to pick up the call light from the floor.
During an observation on 8/27/2024 at 11:48 a.m. in the bedroom, Resident 181 had a push button call light attached to the left side of the bed.
During a concurrent observation and interview on 8/30/2024 at 9:34 a.m. in Resident 181's bedroom, Resident 181 was lying in bed with the push button call light attached to the left side of the bed. Resident 181's left hand was visibly shaky as Resident 181 attempted to push the call light's button. Resident 181 activated the light after two attempts.
During a concurrent observation and interview on 8/30/2024 at 9:47 a.m. with Registered Nurse 6 (RN 6) in Resident 181's bedroom, RN 6 observed Resident 181 use the call light. Resident 181 attempted to push the call light button with visibly shaky hands. Resident 181 stated it was difficult to push the button because Resident 181's hands kept shaking. RN 6 stated Resident 181's push button call light was not appropriate for Resident 181. RN 6 stated Resident 181 needed the pad call light (flat call light activated by gross movement).
During a review of the facility's Policy and Procedure (P&P) titled, Accommodation of Needs, revised 3/2021, the P&P indicated the resident's individual needs and preferences were accommodated to the extend possible, including providing adaptive devices and modifications to the physical environment.
During a review of the facility's P&P titled, Call System, Resident, dated 9/2022, the P&P indicated the facility will provide residents with a means to call staff directly for assistance from their bed. The P&P also indicated the facility will provide the resident with an alternative means of communication if the resident has a disability that prevents the resident from making use of the call system.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 66's AR, the AR indicated the facility admitted Resident 66 on 12/19/2023 with diagnoses that inc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 66's AR, the AR indicated the facility admitted Resident 66 on 12/19/2023 with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures (convulsions) over time) and encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing).
During a review of Resident 66's MDS dated [DATE], the MDS indicated, Resident 66 's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 66 was dependent (full staff performance) with oral hygiene, toileting hygiene, shower, lower body dressing, putting on/taking off footwear and personal hygiene.
During a review of Resident 66's History and Physical (H&P) dated 8/23/2024, the H&P indicated Resident 66 did not have the capacity to understand and make decisions.
During an interview and record review of Resident 66's medical record (chart) on 8/27/2024 at 4:41 pm, together with Licensed Vocational Nurse 15 (LVN 15), LVN 15 stated Resident 66 AD Acknowledgement Form was not filled out. The LVN 15 stated, AD Acknowledgement Form needed to be completely filled out by Social Services upon admission.
Based on interview and record review, the facility failed to ensure the residents' Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) and Request for admission and Authorization for Treatment and Medication (RAATM, permission given before a resident receive any type of medical treatment, test or examination) were discussed and written information were provided to the residents and/or responsible parties for four of five sampled residents (Residents 18, 66, 182 and 193).
These failures had the potential for facility staff to provide medical treatment and services against the residents' will.
Findings:
a. During a review of Resident 193's admission Records (AR), the AR indicated Resident 193 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by chemical imbalance in the blood) and respiratory failure (results from inadequate gas exchange by the respiratory system).
During a review of Resident 193's Minimum Data Set (MDS, a resident's assessment and care planning tool), dated 5/2/2024, the MDS indicated, Resident 193 had severely impaired cognition (ability to understand) for daily decision making. Resident 193 was dependent (helper did all of the effort, resident did none of the effort to complete the activity) with eating, oral and toileting hygiene, shower, upper and lower body dressing and personal hygiene.
During a concurrent interview and record review on 8/28/2024 at 9:49 am with Registered Nurse 3 (RN 3), Resident 193's AD acknowledgement form and RAATM were reviewed. RN 3 stated both documents were not filled out, not completed, and not signed upon admission. RN 3 stated the admitting nurse needed to complete the AD acknowledgement form and RAATM form upon admission and acknowledged by the resident and or the responsible party. RN 3 stated the AD directs the facility on how to care for the resident according to their preferences and wishes. RN 3 stated any treatment could not be started without the RAATM signed upon admission.
During an interview on 8/28/2024 at 10:12 am with Social Services Director (SSD), the SSD stated the Physician Orders for Life-Sustaining Treatment (POLST) was not the same and could not replace an AD. SSD stated, a copy of an AD or an AD acknowledgement form needed be completed and signed with each admission and readmission.
During an interview on 8/28/2024 at 4:26 pm with the facility's Director of Nursing (DON), the DON stated all residents should have an AD acknowledgement form and RAATM form completed and signed upon admission. The DON stated the AD provided the facility directive on how to provide daily care for the resident and the RAATM provided the facility authorization for staff to provide treatment and services to the resident.
During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, revised December 2016, the P&P indicated. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative.
During a review of the facility's P&P titled, Health, Medical Condition and Treatment Options, Informing Resident of, revised February 2021, the P&P indicated, Each resident is informed of his/her health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance of treatment and on an on-going basis. If a resident has an appointed representative, the representative is also informed.
c. During a review of Resident 18's AR, the AR indicated Resident 18 was readmitted to the facility on [DATE], with diagnoses including dementia (loss ability to think, remember and reason) and depression (a mental health condition that characterized by low mood, loss of interest in activities).
During a review of Resident 18's MDS dated [DATE], the MDS indicated Resident 18 had clear speech, sometimes made self-understood and usually understood others. Resident 18 required substantial/maximal assistance (helper does more than half the effort) for personal hygiene, dressing and toilet transfer.
During a review of Resident 18's Advance Directive Acknowledgement form, dated 8/20/2024, the form indicated Resident 18 had executed an AD.
During a review of Resident 18's medical record, there was no AD in Resident 18's medical record (chart).
During an interview and concurrent record review with Social Service Director 2 (SSD 2) on 8/27/2024 at 3:20 pm, SSD 2 stated, Resident 18's had executed an AD and Resident 18's AD should be placed in Resident 18's medical record, so staff would know Resident 18's treatment choices and wishes and would not treat against Resident 18's will.
During a review of the facility's Policy and Procedure (P&P) titled Advance Directives, revised 12/2016, the P&P indicated Prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.
d. During a review of Resident 182's AR, the AR indicated Resident 182 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM, chronic condition when blood glucose is elevated) with a foot ulcer (a skin sore with full thickness skin loss on the foot due to neuropathic (weakness, numbness, and pain from nerve damage) and/or vascular (vessels that carry blood) complications in patients with type 1 or type 2 DM), dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), and essential (primary) hypertension (high blood pressure).
During a review of Resident 182's History and Physical (H&P), dated 7/3/2024, H&P indicated, Resident 182 did not have the capacity to understand and make decisions.
During a review of Resident 182 MDS dated [DATE], the MDS indicated, Resident 182 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 182 was dependent (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) for eating, oral hygiene, showering/bathing self, and upper and lower body dressing. The MDS indicated Resident 182 required substantial/maximal assistance (helper does more than half the effort) for rolling left to right (the ability to roll from lying on back to left and right side and return to lying on back on the bed).
During a review of Resident 182's ADA, dated 7/17/2024, the ADA indicated Resident 182 did not have the capacity to make decisions per the H&P. Resident 182's ADA did not indicate if Resident 182 had an AD.
During a concurrent interview and record review on 8/28/2024 at 12:15 pm, with a Licensed Vocational Nurse 3, LVN 3 stated Resident 182 did not have an AD in the chart. LVN 3 stated Resident 182 had an ADA, but it did not indicate if Resident 182 did or did not have an AD.
During an interview on 8/29/2024 at 9:59 am with the Social Services Director 2 (SSD 2), SSD 2 stated SSD 2 should find out from Resident 182's family to confirm if Resident 182 did not have an AD. SSD 2 stated it was always better to confirm if there was an AD.
During a concurrent interview and record review on 8/29/2024 at 10:29 am with SSD 2, SSD 2 stated SSD 2's notes indicated, on 7/9/2024 at 11:07 am, SSD 2 spoke to Resident 182's family member about Resident 182's AD. SSD 2 stated SSD 2's notes indicated, Resident 182's family member was going to ask another family member and would provide a copy of the AD. SSD 2 stated SSD 2 did not follow up if Resident 182 had an AD. SSD 2 stated SSD 2 should have followed up so that the facility staff would know if Resident 182 had an AD so that Resident 182's wishes could be followed.
During a review of the facility's Policy & Procedure (P&P), titled, Advance Directives, revised December 2016, the P&P indicated information about whether or not the resident has executed an advance directive should be displayed prominently in the medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an ass...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) were accurate for two of five sampled residents (Residents 184 and 216) by:
a. Failing to assess and submit Resident 184's discharge assessment to the Centers of Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency timely. Resident 184 was discharge to General Acute Care Hospital (GACH) on 4/5/2024.
b. Failing to ensure Resident 216 who was discharged home was coded in the MDS assessment accurately.
These deficient practices resulted in an inaccurate reporting to CMS agency and had the potential to result in Residents 184 ad 216 not to receive interventions to address specific care concerns upon discharge.
Findings:
a. During a review of Resident 184's admission Record (AR), the AR indicated Resident 184 was admitted to the facility on [DATE] with diagnoses that included anemia (decrease in the total amount of red blood cells in the blood) and hypertension (high blood pressure).
During a review of Resident 184's Physician's Order (PO) dated 4/5/2024, the PO indicated to transfer Resident 184 to GACH for worsening renal (kidney) function.
During an interview and record review on 8/30/2024 at 9:53 am, with the facility's Minimum Data Set Nurse (MDSN), the MDSN stated Resident 184 was discharged to GACH on 4/5/2024. The MDSN stated, Resident 184's MDS discharged assessment to GACH was needed to be completed and submitted to CMS on 4/5/2024. The MDSN stated Resident 184 discharge assessment to GACH needed to be submitted to CMS to give accurate information in a timely manner and for Resident 184's continuity of care.
During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessments, dated 3/2022, the P&P indicated, the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducted timely and appropriate resident assessments and reviews according to the following requirements: OBRA required assessments conducted for all residents in the facility, such as discharge assessment.
b. During a review of Resident 216's AR, the AR indicated Resident 216 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and asthma (a condition in which a person's airways become inflamed, narrowed, and swollen).
During a review of Resident 216's MDS dated [DATE], the MDS indicated Resident 216 was discharged to the short-term general hospital (acute hospital).
During a review of Resident 216's Physician Orders List (POL), dated 5/29/2024, the POL indicated Resident 216 had an order to discharge the resident to home per family/patient request with medications.
During a review of Resident 216's Physician Discharge Summary (PDS) dated 5/29/2024, the PDS indicated Resident 216 was discharged to home.
During a concurrent interview and record review on 8/29/2024 at 11:42 am with the Minimum Data Set Coordinator (MDS C), Resident 216's MDS dated [DATE] was reviewed. MDS C stated Resident 216's discharge status was coded as discharged to a short-term general hospital instead of discharge to home. MDS C stated MDS assessment should be accurate for the resident to receive continuity of care at home.
During an interview on 8/30/2024 at 10:56 am with the Director of Nursing (DON), the DON stated accurate assessment and documentation was important for accurate reporting to CMS. The DON stated accurate assessment reflected the overall condition of the resident and the kind of care the resident needed.
During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessments, revised March 2022, the P&P indicated, The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the OBRA and PPS required assessments.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an effective communication method to two of tw...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an effective communication method to two of two non-English speaking sampled residents (Resident 522 and 136).
This failure had the potential to result in resident not receiving necessary care and services.
Findings:
a. During a review of the Resident 522's admission Record (AR), the AR indicated Resident 522 was admitted on [DATE].
During a review of Resident 522's History and Physical (H&P) examination, dated 8/13/2024, the H&P indicated Resident 522 was admitted to the facility for uterine cancer (cancer of the uterus) and hypertension (increased blood pressure). The H&P indicated Resident 522 had the capacity to make decisions.
During a review of Resident 522's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 8/16/2024, the MDS indicated Resident 522's language preference was Spanish. Resident 522 had clear speech, had the ability to understand others and made self-understood. Resident 522 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene, upper body dressing, and rolling left and right.
During an observation and a concurrent interview on 8/27/2024 at 11:53 am, in Resident 522's room, Resident 522 was lying in bed awake. Resident 522 stated Resident 522 did not speak English. Resident 522 stated Resident 522 spoke Spanish only. There was no communication board (a paper or device that helps people with limited language skills communicate with others by using symbols, photos, or illustration) at Resident 522's bed side. Certified Nursing Assistant 7 (CNA7) stated, Resident 522 did not speak English and there was no communication board found at Resident 522's bedside. CNA 7 stated, non-English speaking residents should have communication board at bedside for easy communication with staff, so that staffs would be able to attend the resident's needs to provide quality care. CNA7 stated, CNA7 was not aware that the facility had other methods for communicate with non-English speaking residents.
During an interview with Social Service Director 2 (SSD 2) on 8/29/2024 at 9:11 am, SSD 2 stated the facility should provide and keep communication board at resident's bed side for those non-English speaking residents (Resident 522) to easily understand the resident and for staff to address the resident's needs promptly.
During a review of Resident 552's plan of care for language barrier dated 8/29/2024, the plan of care indicated the resident was unable to communicate in English and was Spanish speaking. The care plan interventions included the use of communication board.
During a review of the facility's Policy and Procedure (P&P) titled Translation and/or Interpretation of Facility Services, revised 5/2017, the P&P indicated This facility's language access program will ensure that individual with limited English proficiency shall have meaningful access to information and services provided by the facility.
b. During a review of Resident 136's AR, the AR indicated the facility readmitted the resident on 7/30/24, with diagnoses that included diabetes mellitus (a condition that happens when the blood sugar [glucose] is too high) and hypertensive heart disease with heart failure (a condition that occurs when chronic high blood pressure causes heart failure and other disorders).
During a review of Resident 136's Care Plan (CP) titled, Communication problem related to resident does not understand English language, dated 8/1/24, the CP indicated Resident 136 would be able to communicate needs daily using assistive device such as communication board, letterboard and memory book.
During an observation and concurrent interview on 8/27/24 at 4:25 p.m., Resident 136 was awake, lying on her back in bed with tracheostomy tube (an opening surgically created through the neck into the trachea [windpipe]to allow air to fill the lungs) attached to a ventilator (a type of breathing apparatus that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breathes to a patient who is physically unable to breathe ,or breathing insufficiently). Licensed Vocational Nurse 17 (LVN 17) was present in Resident 136's room. LVN 17 stated Resident 136 only understand Chinese. There was no communication board and/or other functional communication system in Chinese available at the resident's bed side table for Resident 136 to communicate her needs to staff. LVN 17 stated he was unable to find a communication board after he searched Resident 136's closet and bed side table.
During an interview on 8/27/24 at 4:29 p.m., LVN 17 stated communication board should always be available at resident's bed side table to avoid delay of care in case of an emergency for a non-English speaking resident. LVN 17 stated communication board and/or other functional communication system such as reusable writing pad or google translate was necessary for better communication between the resident and staff so that appropriate care could be given to Resident 136.
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 promote healing and provide necessary treatments to pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote healing and provide necessary treatments to prevent the development of pressure ulcer (lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) for five of six sampled residents (Residents 64, 91, 141, 162 and 182) by failing to:
a. Ensure the low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure injuries) for Resident 64 was set to alternating pressure.
b. Ensure the LAL mattress for Resident 162 was set to alternating pressure.
c. Ensure the LAL mattress for Resident 141 was set to therapeutic mode and in accordance with the resident's weight.
d. Ensure Resident 91 was not lying on the site of the pressure ulcer and was repositioned every two hours while in bed.
e. Ensure Resident 182 was wearing heel protectors as ordered.
These failures had the potential for the residents to develop pressure ulcer, worsen the pressure ulcer or prevent healing of the pressure ulcer.
Findings:
a. During a review of Resident 64's admission Record (AR), the AR indicated Resident 64 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body ) following cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain) affecting the right dominant side of the body.
During a review of Resident 64's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 5/30/2024, the MDS indicated Resident 64 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), required the assistance of two or more helpers to roll from lying on back to left and right side, and return to lying on back on the bed, and was at risk of developing pressure ulcers/injuries.
During a review of Resident 64's Treatment Administration Record (TAR) from 8/1/2024 through 8/31/2024, the TAR indicated treatment for a re-opened surgical scar on Resident 64's right hip, started on 8/21/2024 for 21 days .
During a review of Resident 64's Wound Consult Progress Note (WCPN) dated 8/14/2024, the WCPN indicated Resident 64 had a surgical wound on the right hip that was not healed and measured 1.5 centimeter (cm- unit of measurement) in length by 1.0 cm in width by 2.4 cm in depth and a resolved right buttock stage 3 pressure ulcer. The WCPN recommended to implement pressure relieving measures and the use of a LAL mattress for Resident 64.
During a review of Resident 64's Order Summary Report (OSR), the OSR indicated an order on 8/21/2024 to monitor for the LAL mattress pressure setting every shift. The order indicated Resident 64's LAL mattress should be set according to resident's weight/comfort and was ordered for wound management.
During an observation on 8/27/2024 at 11:18 am in Resident 64's room, Resident 64 was asleep in bed. Resident 64's LAL mattress was set on the static mode (a setting that creates a firm surface), pressure-adjust knob (weight setting knob) was at 210 pounds (lbs.) with the normal pressure indicator (a visible indicator (green) which shows the pressure has reached a preset or user-defined level) lit.
During a concurrent observation and interview on 8/27/2024 at 11:54 am with Treatment Nurse 1 (TN 1) in Resident 64's room, Resident 64's LAL mattress was set to the static mode and the pressure-adjust knob was at 210 lbs. and the normal pressure indicator was lit. TN 1 stated, Resident 64 was receiving wound treatments for a previous surgical wound on his hip that had re-opened. TN 1 switched the static/alternating control switch off from static mode to alternating pressure mode. TN 1 stated, Resident 64's LAL mattress should be at the right settings to prevent it from being either too hard or too soft for the resident. TN 1 stated Resident 64's LAL mattress should not be on static mode to allow the cells in the mattress to fluctuate and relieve pressure for the resident.
b. During a review of Resident 162's AR, the AR indicated Resident 162 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included peripheral vascular disease (PVD- a systemic disorder that involves the narrowing of peripheral blood vessels), functional quadriplegia (complete inability to move due to severe physical disability or frailty) and pressure ulcer of sacral region, Stage 4 (ulcer that extends into the muscle and bone and causing extensive damage).
During a review of Resident 162's MDS dated [DATE], the MDS indicated Resident 162 was cognitively intact. The MDS indicated Resident 162 required assistance of two or more helpers for bed mobility, was at risk for developing pressure ulcers/injuries, had two venous and arterial ulcers present, and required a pressure reducing device for the bed as a skin and ulcer/injury treatment.
During a review of Resident 162's OSR, the OSR indicated an order on 7/29/2024 to monitor for the LAL mattress pressure setting every shift. The order indicated the LAL mattress should be set according to Resident 162's weight/comfort and was ordered for wound management.
During a review of Resident 162's Wound Assessment Report dated 7/31/2024, the Wound Assessment Report indicated Resident 162 had a(n):
1. Left heel arterial ulcer (painful, deep sore or wound in the skin of the lower leg or foot caused by poor circulation) identified on 3/20/204 and measured 3.5 cm in length by 3.0 cm in width.
2. Open wound on the right knee identified on 1/27/2024 and measured 1.8 cm in length by 1.2 cm in width by 0.3 cm in depth.
3. Left first metatarsal head (bone in the foot just behind the big toe) arterial ulcer identified on 1/27/2024 and measured 0.5 cm in length by 0.5 cm in width.
During a review of Resident 162's untiled Care Plan (CP) revised on 8/4/2024, the CP indicated Resident 162 had the potential for pressure ulcer development related to the resident's disease process and immobility. The CP indicated an intervention to follow facility's policies and protocols for the prevention and treatment of skin breakdown.
During a review of Resident 162's untitled CP revised on 8/4/2024, the CP indicated Resident 162 had potential impairment to skin integrity related to fragile skin with interventions including staff to monitor the LAL mattress pressure settings every shift.
During an observation on 8/27/2024 at 11:26 am in Resident 162's room, Resident 162 was in bed and Resident 162's left foot was wrapped in a dressing. Resident 162's LAL mattress was set on the static mode, the pressure-adjust knob at 80 pounds (lbs.), and a normal pressure was indicated.
During a concurrent observation and interview on 8/27/2024 at 11:47 am with TN 1in Resident 162's room, Resident 162's LAL mattress was set to the static mode and the pressure adjustment knob was at 80 lbs. TN 1 stated, Resident 162 was receiving wound treatments for diabetic ulcers and had been seen by TN 1 that morning (8/27/2024). TN 1 switched the static/alternating control switch off from static mode to alternating pressure mode. TN 1 stated, the LAL mattress should be at the right setting for Resident 162 to prevent it from being either too hard or too soft. TN 1 stated, Resident 162's LAL mattress should not be on static mode to allow the cells in the mattress to fluctuate and relieve pressure for the resident.
During a review of the manufacturer's manual titled . Alternating Pressure Low Air Loss Mattress Replacement System with Low Air Loss Operator's Manual Item #14026, (undated), the manual indicated the mattress came with an air cell mattress that provided low air loss, alternation (changing pressure) and static pressure redistribution therapy and was for the prevention and treatment of any and all pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. The manual indicated, the static control button was used to shift between alternating and static mode and when in static mode, the static indicator will turn on and the mattress will become a firm surface.
During a review of the facility's Policy and Procedure (P&P) titled, Support Surface Guidelines, revised September 2013, the P&P indicated, redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Elements of support surfaces that are critical to pressure ulcer prevention and general safety also include pressure redistribution.
c. During a review of Resident 141's AR, the AR indicated Resident 141 was readmitted to the facility on [DATE], with diagnoses including dysphagia (difficulty swallowing) and type 2 diabetes mellitus (a chronic disease resulting in high blood sugar level).
During a review of Resident 141's MDS dated [DATE], the MDS indicated Resident 141 had clear speech, usually understood others, and made self-understood. Resident 141 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene, dressing, and rolling left and right. Resident 141's MDS indicated Resident 141 weighed 144 pounds (lbs.).
During a review of Resident 141's Order Summary Report (OSR) dated 8/28/2024, the OSR indicated Resident 141 had an order for pressure relieving Low Airloss Mattress (LAL) mattress, set to alternating and weight of resident for wound management every shift.
During an observation and concurrent interview on 8/27/2024 at 11:13 am, in Resident 141's room, Resident 141 was lying in bed on LAL mattress. Resident 141's LAL mattress was set at 320 lbs. and at static mode. Licensed Vocational Nurse 3 (LVN 3) stated, Resident 141's LAL mattress should not be set up at 320 lbs. and should be set based on Resident 141's weight and alternative mode per physician's order to prevent Resident 141 from skin breakdown (damage to skin).
During an interview on 8/29/2024 at 4:11 pm, Treatment Nurse 1 (TN 1) stated, Resident 141's LAL mattress should be set by weight using alternative mode following the physician's order. TN 1 stated, the facility used LAL mattress for prevent pressure injury and wound management to release pressure from the pressure point. TN 1 stated, if LAL mattress was not set up correctly, it would defeat the purpose of using it and would delay wound healing.
During a review of the facility's P&P tilted Support Surface Guidelines, revised 9/2013, the P&P indicated Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface such as air-loss device when lying in bed.
e. During a review of Resident 182's AR, the AR indicated Resident 182 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM, chronic condition when blood glucose is elevated) with a foot ulcer (a skin sore with full thickness skin loss on the foot due to neuropathic (weakness, numbness, and pain from nerve damage) and/or vascular (vessels that carry blood) complications in patients with type 1 or type 2 DM), dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), and essential (primary) hypertension (high blood pressure).
During a review of Resident 182's History and Physical (H&P), dated 7/3/2024, H&P indicated, Resident 182 did not have the capacity to understand and make decisions.
During a review of Resident 182 MDS dated [DATE], the MDS indicated, Resident 182 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 182 was dependent (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) for eating, oral hygiene, showering/bathing self, and upper and lower body dressing. The MDS indicated Resident 182 required substantial/maximal assistance (helper does more than half the effort) for rolling left to right (the ability to roll from lying on back to left and right side and return to lying on back on the bed).
During a review of Resident 182's Braden Risk Assessment Report, dated 7/17/2024, indicated, Resident 182 was at mild risk.
During a review of Resident 182's Physician Orders (PO), dated 7/30/2024, the PO indicated, for Resident 182 to use heel protectors (supportive device to assist in minimizing the risk of pressure damage to heels) when in bed for wound management.
During a review of Resident 182's Progress Notes (PN), dated 8/15/2024 at 6:31 pm, the PN indicated, Resident 182 had a re-opened right heel diabetic ulcer measuring 1.5 cm (centimeter, unit of measurement) x 3 cm x UTD (undetermined).
During a review of Resident 182's PN, dated 8/27/2024 and timed at 4:52 pm, the PN indicated, Resident 182 had a left heel diabetic ulcer measuring 1 x 1 cm.
During a concurrent observation and interview on 8/28/2024 at 9:36 am with a Licensed Vocational Nurse 7 (LVN 7), Resident 182 was observed with no heel protectors on bilateral (both) feet. LVN 7 stated Resident 182 did not have Resident 182's heel protectors on. LVN 7 stated LVN 7 could not find them, and the heel protectors should be at Resident 182's bedside. LVN 7 stated if Resident 182 does not have the heel protectors on, Resident 182 could acquire further skin breakdown.
During an interview on 8/28/2024 at 10:37 am with a Treatment Nurse 2 (TN 2), TN 2 stated Resident 182 had diabetic ulcers to Resident 182's left and right heels. TN 2 stated Resident 182 needed to wear the heel protectors on at all times while Resident 182 was in bed. TN 2 stated the importance of Resident 182 wearing the heel protector boots was to protect Resident 182's wound and relieve pressure.
During a review of the facility's Policy & Procedure (P&P), titled, Wound Care, revised October 2010, the P&P indicated, to use supportive devices as instructed.
During a review of the facility's P&P, titled, Foot Care, revised October 2022, the P&P indicated, overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions (e.g., diabetes, peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), immobility, etc.).
d. During a review of Resident 91's AR, the AR indicated the facility initially admitted the resident on 6/8/20, and was readmitted on [DATE], with diagnoses that included diabetes mellitus (a condition that happens when the blood sugar [glucose] is too high) and quadriplegia (paralysis of all four limbs).
During a review of Resident 91's Wound Assessment Report (WAR) dated 6/8/20, the WAR indicated Resident 91 was admitted with a Stage 4 pressure ulcer (full thickness and tissue loss with exposed bone, tendon, or muscle) of sacral (a triangular shape bone at the bottom of the spine) coccyx (tail bone) area and the pressure ulcer was resolve on 10/12/22.
During a review of Resident 91's WAR dated 8/24/23, the WAR indicated Resident 91 had a reopened Stage 4 pressure ulcer of sacral coccyx that measured 2 centimeter ([cm]unit of measurement) in length(L) by (x) 2 cm in width.
During a review of Resident 91's Care Plan (CP) titled, At risk for skin breakdown related to admitted with pressure injury dated 8/9/24, the CP indicated Resident 91 was to be turned and repositioned at least every two hours in bed.
During observations on 8/27/24 at 11:50 p.m., 1:05 p.m., and 2:15 p.m., Resident 91 was observed lying on his back on a low air loss mattress (a mattress that provides a flow of air to assist in managing the heat and humidity of the skin). Resident 91 was awake and non-communicative.
During a concurrent observation and interview on 8/27/24 at 3:35 p.m., Resident 91 was lying on his back in bed. The Certified Nursing Assistant 4 (CNA 4) stated Resident 91 should be turned and repositioned only side to side to prevent pressure on sacral coccyx pressure ulcer when Resident 91 was lying in bed. CNA 4 stated Resident 91 should not be lying on the site of pressure ulcer (sacral coccyx) because the wound would not heal and /or get worse due to poor circulation from pressure in the wound. CNA 4 stated she was aware Resident 91 was to be turned and repositioned every two hours but failed to do so.
During the treatment observation on 8/29/24 at 10:23 p.m., Resident 91 was observed with a Stage 4 pressure ulcer of sacral coccyx that measured 3.5 cm(L) x 2.5 cm (W), depth 2 cm, undermining at 1-3 o'clock, no tunneling. The wound bed (base of the wound) had moderate amount of yellow slough (dead tissue).
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 ensure three of five sampled residents (Residents 36,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Residents 36, 109 and 135) with limited range of motion (ROM- full movement potential of a joint [where two bones meet]) and mobility (ability to move) received treatment and services to prevent further decline in ROM by failing to:
1. Provide Resident 36 with ROM exercises on both wrists, hands, and ankles in accordance with the physician's orders.
2. Identify and report Resident 36's right elbow splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) was not aligned with Resident 36's right elbow to the Occupational Therapist ([OT] professional aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]).
3. Provide Resident 109 with ROM exercises on the left elbow, both wrists, both hands, the left knee, and both ankles in accordance with the physician orders.
4. Provide Resident 135 with ROM exercises on both wrists, hands, and ankles in accordance with the physician's orders.
5. Include ROM of the ankles in the facility's Policy and Procedure (P&P) titled, Range of Motion Exercises.
These failures had the potential for Residents 36, 109, and 135 to experience a decline in ROM and the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness).
Findings:
a. During a review of Resident 36's admission Record (AR), the AR indicated the facility originally admitted Resident 36 on 12/15/2010 and readmitted on [DATE]. The AR indicated Resident 36's diagnoses included hemiplegia (weakness or difficulty to move one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant side (more often used during the completion of daily living tasks), muscle weakness, dysphagia (difficulty swallowing), and aphasia (loss of ability to understand or express speech as a result of brain damage).
During a review of Resident 36's Physician Orders (PO) dated 2/9/2024, the PO indicated for Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) to provide PROM exercises to Resident 36's both arms and legs, five times per week as tolerated. Another PO dated 2/9/2024, indicated for the RNA to apply a right elbow splint for up to six hours, five times per week as tolerated. Another PO dated 2/9/2024 indicated for RNA to apply both ankle foot orthoses ([AFO] brace to hold the foot and ankle in the correct position) for four to six hours, five times per week as tolerated.
During a review of Resident 36's Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs), dated 2/9/2024, 5/9/2024, and 7/10/2024, the JMA indicated Resident 36 had minimal (25 to 60 percent [%] ROM limitation) to moderate (60 to 75% ROM limitation) ROM limitations in both shoulders and minimal ROM limitation in the right elbow. The JMA indicated for Resident 36 to receive RNA.
During a review of Resident 36's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 6/10/2024, the MDS indicated Resident 36 had unclear speech, had difficulty communicating words or finishing thoughts, understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 36 had functional ROM impairments in one arm and both legs and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for eating, dressing, rolling to both sides in bed, and chair/bed-to-chair transfers.
During an interview on 8/27/2024 at 10:34 a.m. with the Director of Rehabilitation (DOR), the DOR stated the RNAs provided maintenance services including ROM exercises and application of splints. The DOR stated ROM exercises (in general) maintained a resident's joint mobility and muscle length. The DOR stated the purpose of splints (in general) included to maintain or improve a resident's ROM.
During an observation on 8/28/2024 at 9:55 a.m. in Resident 36's bedroom, Resident 36's RNA session was observed while Resident 36 was awake, lying in bed. Restorative Nursing Aide 3 (RNA 3) stood on the right of Resident 36's bed to perform ROM exercises on Resident 36's right arm, including shoulder abduction (lifting the arm up and away from the body), elbow flexion (bending), and elbow extension (straightening). RNA 3 did not provide any ROM exercises on the right wrist and hand. RNA 3 walked to the left side of the bed to perform ROM exercises on the left arm, including shoulder flexion (lifting the arm upward), shoulder abduction, elbow flexion, and elbow extension. RNA 3 did not provide any ROM exercises on the left wrist and hand. RNA 3 retrieved Resident 36's right elbow splint and both AFOs from Resident 36's closet. The elbow splint had a slight bend while Resident 36's right elbow was bent more than 90 degrees. RNA 3 applied the splint to Resident 36's right elbow. RNA 3 provided exercises to both legs, including hip abduction (moving the leg away from the body) and knee flexion. RNA 3 did not perform any ROM exercises to both ankles but applied both AFOs.
During an interview on 8/28/2024 at 10:12 a.m. with RNA 3, RNA 3 stated ROM exercises were performed to both of Resident 36's arms and the elbow splint was applied to Resident 36's right arm. RNA 3 stated ROM exercises were performed to both of Resident 36's legs and both AFOs were applied. RNA 3 stated ROM exercises were not provided to both wrists, hands, and ankles because RNA 3 was nervous.
During an interview on 8/28/2024 at 10:21 a.m. with the DOR and Occupational Therapist 1 (OT 1), OT 1 stated the ROM exercises RNAs should provide to the arms included the shoulder, elbow, wrist, and hand joints. The DOR stated the ROM exercises RNAs should provide to the leg included the hip, knee, ankle, and toe joints. OT 1 stated performing ROM to each joint reduces the risk of developing contractures.
During a concurrent observation and interview on 8/28/2024 at 10:35 a.m. with OT 1 in Resident 36's bedroom, Resident 36 was observed wearing the right elbow splint. OT 1 measured Resident 36's right elbow while wearing the right elbow splint and stated Resident 36's right elbow was bent to 115 degrees of flexion. OT 1 removed Resident 36's right elbow splint, which measured to 55 degrees of flexion. OT 1 stated Resident 36's right elbow splint did not fit and was not reported to OT 1. OT 1 adjusted Resident 36's right elbow splint.
During an interview on 8/28/2024 at 10:42 a.m. with OT 1, OT 1 stated Resident 36's right elbow splint was bent into additional flexion to improve the fit onto Resident 36's elbow. OT 1 stated a splint could cause skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure) if the splint did not fit properly.
During an interview on 8/29/2024 at 11:20 a.m. with RNA 3, RNA 3 stated she did not receive training specifically on the application of Resident 36's right elbow splint.
b. During a review of Resident 109's AR, the AR indicated the facility admitted Resident 109 on 3/20/2024 and re-admitted on [DATE]. The AR indicated Resident 109's diagnoses included parkinsonism (group of conditions with symptoms including slow movements, stiffness, tremors, and balance issues), dementia (decline in mental ability severe enough to interfere with daily life), dysphagia (difficulty swallowing), attention to tracheostomy (surgical opening made through the front of the neck and into the windpipe [trachea] to allow air into the lungs), dependence on a ventilator (machine that mechanically assists with breathing) and attention to gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding).
During a review of Resident 109's MDS dated [DATE], the MDS indicated Resident 109 had severely impaired cognition (ability to think, understand, learn, and remember), impaired ROM to both arms and legs, and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for oral hygiene, toileting, dressing, and rolling to both sides in bed.
During a review of Resident 109's JMA dated 8/8/2024, the JMA indicated Resident 109 had minimal ROM limitations (25 to 60 percent [%] ROM limitation) in both shoulders and the left elbow. The JMA indicated for Resident 109 to receive RNA.
During a review of Resident 109's PO dated 8/8/2024, the PO indicated for the RNA to provide PROM to both arms and both legs, five times per week. Anther PO dated 8/8/2024 indicated for the RNA to apply an elbow splint on Resident 109's left arm for up to six hours, five times per week.
During an interview on 8/27/2024 at 10:34 a.m. with the DOR, the DOR stated the RNAs provided maintenance services including ROM exercises and application of splints. The DOR stated ROM exercises (in general) maintained a resident's joint mobility and muscle length.
During an observation on 8/28/2024 at 9:25 a.m. in Resident 109's bedroom, Resident 109's RNA session was observed. Restorative Nursing Aide 4 (RNA 4) stood on the left side of Resident 109's bed and performed ROM to Resident 109's left shoulder into flexion. RNA 4 did not perform any ROM exercises to Resident 109's left elbow, wrist, and hand. RNA 4 then moved to the right side of Resident 109's bed. RNA 4 performed ROM exercises to Resident 109's right shoulder, including flexion and abduction but suddenly stopped the exercises. RNA 4 stated the right shoulder exercises were stopped because Resident 109's facial expression showed Resident 109 was in pain. RNA 4 returned to the left side of Resident 109's bed and performed left hip exercises into abduction (moving the leg away from the body). RNA 4 did not perform any ROM exercises to the left knee and ankle. RNA 4 went to the right side of Resident 109's bed and performed exercises to the right leg, including hip abduction and knee flexion (bending). RNA 4 did not perform any ROM exercises to the left ankle. RNA 4 applied the elbow splint to Resident 109's left elbow.
During an interview on 8/28/2024 at 9:37 a.m. with RNA 3, RNA 3 stated Resident 109 was seen for ROM exercises to both arms, both legs, and application of the left elbow splint. RNA 3 stated ROM exercises were not performed to the left elbow, both wrists, both hands, the left knee, and both ankles because RNA 3 felt nervous.
During an interview on 8/28/2024 at 10:21 a.m. with the DOR and Occupational Therapist 1 (OT 1), OT 1 stated the ROM exercises RNAs should provide to the arms included the shoulder, elbow, wrist, and hand joints. The DOR stated the ROM exercises RNAs should provide to the leg included the hip, knee, ankle, and toe joints. OT 1 stated performing ROM to each joint reduces the risk of developing contractures.
c. During a review of Resident 135's AR, the AR indicated the facility admitted Resident 135 on 6/6/2023 and readmitted on [DATE]. The AR indicated Resident 135's diagnoses included amyotrophic lateral sclerosis (ALS, disease of the nerve cells in the brain and spinal cord that control voluntary muscle movement and breathing), attention to tracheostomy, dependence on a ventilator and attention to gastrostomy tube.
During a review of Resident 135's JMA dated 10/22/2023, the JMA indicated Resident 135's both shoulders had minimal (25 to 60 percent [%] ROM limitation) ROM limitations and both ankles had moderate (60 to 75% ROM limitation) to severe (75 to 100%) ROM limitations. The JMA indicated recommendations for Resident 135 to receive RNA.
During a review of Resident 135's PO dated 10/22/2023, the PO indicated for the RNA to provide Resident 135 PROM to both legs, five times per week as tolerated. Another PO dated 2/29/2024 indicated for the RNA to provide PROM to both arms, five times per week as tolerated.
During a review of Resident 135's MDS dated [DATE], the MDS indicated Resident 135 understood verbal content, expressed ideas and wants, and had intact cognition. The MDS indicated Resident 135 had ROM impairments to both arms and legs and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for oral hygiene, toileting, dressing, and rolling to both sides in bed.
During an interview on 8/27/2024 at 10:34 a.m. with the Director of Rehabilitation (DOR), the DOR stated the RNAs provided maintenance services including ROM exercises and application of splints. The DOR stated ROM exercises (in general) maintained a resident's joint mobility and muscle length.
During an observation on 8/28/2024 at 8:42 a.m. in Resident 135's bedroom, Resident 135's RNA session was observed. Resident 135 was lying in bed with both arms resting on pillows on either side of Resident 135's body. Restorative Nursing Aide 2 (RNA 2) stood on the right side of Resident 135's bed to perform ROM exercises to Resident 135's right arm, including shoulder flexion (lifting the arm upward), shoulder abduction (lifting the arm up and away from the body), and elbow flexion (bending). RNA 2 proceeded to perform ROM exercises to Resident 135's right leg, including hip flexion (bending the leg at the hip joint toward the body), hip abduction (moving the leg away from the body) and knee flexion. RNA 2 walked to the left side of Resident 135's bed to perform ROM exercises to Resident 135's left leg, including hip flexion, hip abduction, and knee flexion. RNA 2 performed ROM exercises on Resident 135's left arm, including the shoulder flexion, shoulder abduction, and elbow flexion. RNA 2 did not perform any ROM exercises to both of Resident 135's wrists, hands, and ankles.
During an interview on 8/28/2024 at 8:59 a.m. with RNA 2, RNA 2 stated Resident 135 was seen for ROM to both arms and both legs.
During an interview on 8/28/2024 at 9:16 a.m. with RNA 2, RNA 2 stated RNA 2 forgot but should have performed ROM exercises on both of Resident 135's wrists, hands, and ankles.
During an interview on 8/28/2024 at 10:21 a.m. with the DOR and Occupational Therapist 1 (OT 1), OT 1 stated the ROM exercises RNAs should provide to the arms included the shoulder, elbow, wrist, and hand joints. The DOR stated the ROM exercises RNAs should provide to the leg included the hip, knee, ankle, and toe joints. OT 1 stated performing ROM to each joint reduces the risk of developing contractures.
During a concurrent interview and record review on 8/29/2024 at 1:46 p.m. with the Director of Staff Development (DSD), the DSD reviewed the facility's P&P titled, Range of Motion Exercises, revised 10/2010. The DSD stated the facility's policy for ROM exercises did not include but should include performing ROM exercises to the ankle. The DSD stated the RNA should perform ROM exercises on all joints of the arm, including the shoulder, elbow, wrist, and hand, and all joints of the leg, including the hip, knee, and ankle. The DSD stated performing ROM to all joints prevented decline in ROM and the development of contractures. The DSD stated the RNA did not perform ROM correctly if any joints were missed.
During a review of the facility's P&P titled, Range of Motion Exercises, revised 10/2010, the P&P indicated the purpose of the procedure was to exercise the resident's joints and muscles. The P&P included exercises to the neck, shoulder, elbow, wrist, hand, hip, knee, and feet but did not include ROM exercises for the ankles.
During a review of the facility's P&P titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
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, for two of two sampled residents (Residents 199 and 521), the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for two of two sampled residents (Residents 199 and 521), the facility failed to:
a. Label and date the peripheral intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products) for Resident 199 in accordance with facility's Policy and Procedure (P&P) on Administration Set/Tubing Changes and Resident 199's care plan.
b. Ensure Resident 521's PICC line (a type of long catheter that is inserted through a peripheral vein into larger vein in the body, used to deliver medications and other treatments directly to the large central veins) dressing was kept clean, not soiled, and changed in accordance with the facility's P&P on Central Venous Catheter Dressing Changes.
These failures had the potential to result in infection to Residents 199 and 521.
Findings:
a. During a review of Resident 199's admission Record (AR), the AR indicated Resident 199 was admitted to the facility on [DATE] with diagnoses that included respiratory failure and history of falling.
During a review of Resident 199's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/21/2024, the MDS indicated Resident 199 's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 199 was dependent with oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene.
During a review of Resident 199's untitled Care Plan (CP) initiated in 8/23/2024, the CP Resident 199 was at risk for complications related to intravenous medication. The CP interventions included for nursing staff to monitor the IV site every shift and change IV dressing as ordered by physician.
During a concurrent observation and interview on 8/27/2024 at 10:55 am with Licensed Vocational Nurse 1 (LVN 1), Resident 199 was awake lying in bed with peripheral IV site on the right hand that was not dated when it was changed and inserted. RN 1 stated Resident 199's IV site was not labeled with date, time and initial to identify when it was inserted by the licensed nurse.
During an interview on 8/27/2024 at 11:18 am with Registered Nurse 2 (RN 2), RN 2 stated Resident 199's peripheral IV site needed to be labeled with date and time when it was inserted and the licensed nurse's initial to determine when was it changed, to prevent infection.
During a review of the facility's P&P titled, Administration Set/Tubing Changes dated 2/2023, the P&P indicated to label administration set and tubing with sate, time and initials. b. During a review of Resident 521's AR, the AR indicated Resident 521 was admitted on [DATE].
During a review of Resident 521's Physician's Progress Notes (PPN) dated 8/20/2024, the PPN indicated Resident 521 was admitted to the facility for physical therapy, occupational therapy, intravenous medications, and wound care.
During an observation and concurrent interview on 8/27/2024 at 10:58 am, in Resident 521's room, Resident 521 was lying in bed awake. Resident 521 had a PICC line (a type of long catheter that is inserted through a peripheral vein into larger vein in the body, used to deliver medications and other treatments directly to the large central veins) at the right upper arm. The dressing gauze that covered the insertion site was dated 8/7/2024 and was soiled. Registered Nurse 6 (RN 6) stated RN 6 was not aware that Resident 521's PICC line dressing was old and dated 8/7/2024. RN 6 stated, Resident 521's PICC line dressing looked dirty and Resident 521's PICC line should be changed the past Sunday (8/25/2024). RN 6 stated, PICC lines should be changed weekly or as needed if soiled. RN 6 stated, PICC lines were considered as central line, and if PICC lines got dirty, it would place the resident at risk for infections and possible sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection).
During a review of Resident 521's Order Summary Report (OSR) dated 8/29/2024, the OSR indicated Resident 521 had a PICC line to the right upper arm.
During a review of the facility's Policy and Procedure (P&P) titled Central Venous Catheter Dressing Changes, revised 4/2016, the P&P indicated Change transparent semi-permeable membrane dressing at least every 5-7 days and PRN (as needed) when wet, soiled, or not intact. If gauze is used, it must be changed every 2 days.
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** d. During a review of Resident 208's AR, the AR indicated Resident 208 was admitted to the facility on [DATE].
During a review o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. During a review of Resident 208's AR, the AR indicated Resident 208 was admitted to the facility on [DATE].
During a review of Resident 208's History and Physical (H&P) dated 7/11/2024, the H&P indicated the resident had diagnoses including hypertension (high blood pressure) and hyperlipidemia (high cholesterol).
During a review of Resident 208's MDS dated [DATE], the MDS indicated Resident 208 had moderately impaired cognition.
During an observation on 8/27/2024 at 10:42 am in Resident 208's room, Resident 208 was receiving oxygen through a NC at two liters (L) connected to an oxygen concentrator (a medical device that delivers oxygen).
During a concurrent observation and interview on 8/27/2024 at 10:45 am with Licensed Vocational Nurse 9 (LVN 9) in Resident 208's room, Resident 208 was lying in bed receiving oxygen through a NC. LVN 9 stated Resident 208 was receiving two L of oxygen.
During a review of Resident 208's Medication Administration Record (MAR) dated 8/29/2024, the MAR did not indicate an order for oxygen administration to Resident 208.
During a review of Resident 208's Order Summary Report (OSR), dated 8/29/2024 at 1:53 pm, the OSR did not indicate a physician order for oxygen administration for Resident 208.
During a follow up observation and interview on 8/29/2024 at 2:06 pm with LVN 9 in Resident 208's room, Resident 208 was in bed receiving oxygen via NC at two L. LVN 9 stated, Resident 208 received oxygen day and night, but was unaware why Resident 208 was being administered oxygen.
During a concurrent interview and record review on 8/29/2024 at 2:10 pm with LVN 3, Resident 208's physician's orders dated 8/29/2024 were reviewed. LVN 3 stated there was no physician's order for oxygen administration for Resident 208. LVN 3 stated it was necessary to have a physician's order for oxygen administration for Resident 208.
During a review of the facility's Policy and Procedure (P&P) titled, Medication and Treatment Orders, revised July 2016, the P&P indicated medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.
During a review of the facility's P&P titled, Oxygen Administration revised October 2010, the P&P indicated the purpose was to provide guidelines for safe oxygen administration and the first step was to verify that there was a physician's order for oxygen and review the physician's orders or facility protocol for oxygen administration.
b. During a review of Resident 92's admission Record (AR), the AR indicated the facility admitted Resident 92 on 7/3/2024 with diagnoses that included encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing) and dependence on respirator (also known as ventilator which is a machine that supports breathing).
During a review of Resident 92's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/9/2024, the MDS indicated Resident 92 's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated, Resident 92 was dependent (full staff performance) with oral hygiene, toileting hygiene, shower, lower body dressing, putting on/taking off footwear and personal hygiene.
During a review of Resident 92's History and Physical (H&P) dated 8/1/2024, the H&P indicated Resident 92 did not have the capacity to understand and make decisions.
During a review of Resident 92's Care Plan (CP) titled Respiratory Care initiated on 8/1/2024, the CP indicated Resident 92 had impaired gas exchange related to ineffective airway clearance. The CP interventions included for nursing staff to assess respiratory function/monitor airway clearance and suction Resident 92 every two (2) hours and as needed.
During a review of Resident 92's Physician Order (PO) dated 8/4/2024, the PO indicated licensed staff to suction Resident 92's excess secretions every 2 hours or as needed.
During a concurrent observation in Resident 92's room and interview on 8/27/2024, at 11:07 am, with Licensed Vocational Nurse 1 (LVN 1), Resident 92 was asleep, lying in bed with suction bottle at bedside undated with 400 millimeters (ml, unit of measurement) brownish fluid with white sediments. LVN 1 stated, Resident 92's suction bottle needed to be labeled with the date to know when was it changed. LVN 1 stated, it was important to know when the bottle was changed to prevent infection.
During concurrent observation and interview on 8/27/2024, at 11:15 am, with Respiratory Therapist 1 (RT 1), RT 1 stated Residents 92's suction bottle and tubing needed to be labeled with date as to when was it changed because it would be a source of infection. RT 1 stated suction bottle needed to be changed every Wednesday and Friday.
During a review of the facility's P&P titled, Cleaning and Disinfection of Resident - Care Items and Equipment, revised 9/2022, the P&P indicated semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (respiratory therapy equipment). The P&P indicated for critical and semi critical items . equipment to be processed will be labeled with at least the following information: the date and time the label was affixed to the equipment.
c. During a review of Resident 130's admission Records (AR), the AR indicated Resident 130 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included congestive heart failure (a condition in which the heart doesn't pump enough blood to deliver oxygen to the body) and dyspnea (shortness of breath).
During a review of Resident 130's Minimum Data Set (MDS, a resident's assessment and care planning tool) dated 5/15/2024, the MDS indicated Resident 130 had an intact cognition (ability to understand). The MDS indicated Resident 130 required moderate assistance (helper did less than half the effort) with oral and personal hygiene and totally dependent (helper did all of the effort, resident did none of the effort to complete the activity) with toileting, shower, upper and lower body dressing.
During a review of Resident 130's Order Summary Report (OSR) dated 7/6/2024, the OSR indicated Resident 130 had an order for oxygen at 2-4 liters via nasal cannula (L/NC, amount of oxygen delivered by nasal cannula) to keep oxygen saturation (a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) above 90 percent (%) for dyspnea (difficulty breathing).
During a concurrent observation and interview on 8/27/2024 at 10:01 am with Registered Nurse Supervisor 1 (RN 1) inside Resident 130's room, Resident 130 was lying in bed on her back with ongoing oxygen therapy. Resident 130 stated Resident 130's NC tubing had not been changed for 3 weeks. RN 1 stated Resident 130's NC tubing was not labeled with the date it was changed. RN 1 stated the NC tubing needed to be changed every week and should be labeled with the date each time it was changed to determine it was timely changed and for infection control.
During an interview on 8/28/2024 at 4:26 pm with the Director of Nursing (DON), the DON stated all oxygen tubing needed to be changed weekly and labeled with the date when it was changed to know that it was changed timely and to prevent infection.
During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised October 2010, the P&P indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.
Based on observation, interview, and record review, the facility failed to provide necessary care and services for residents on oxygen therapy (treatment that provides supplemental, or extra oxygen) consistent with professional standards of practice for four of four sampled residents (Residents 23, 92, 130 and 208) by failing to:
a. Follow the physician's order to provide two liters of oxygen inhalation through nasal cannula to Resident 23.
b. Label tracheostomy drainage bottle with date for Resident 92.
c. Label oxygen tubing with date for Resident 130.
d. Ensure Resident 208 had a physician's order for the use of oxygen at two liters per minute through nasal cannula.
These deficient practices placed Residents 23, 92, 130 and 208 at risk for severe difficulty of breathing and serious respiratory complications.
Findings:
a. During a review of Resident 23's admission Record (AR), the AR indicated the facility readmitted the resident on 7/6/23, with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and hypertensive heart disease with heart failure (a condition that occurs when chronic high blood pressure causes heart failure and other disorders).
During a review of the Physician Order Sheet (POS) dated 9/12/23, the POS indicated an order for licensed staff to provide Resident 23 two liters (unit of measurement) per minute of oxygen through nasal cannula (a flexible soft tube that delivers extra oxygen through a tube and into the nose) PRN (whenever necessary) for shortness of breath.
During a review of Resident 23's Care Plan (CP) for oxygen therapy dated 7/6/23, the CP indicated to provide Resident 23 with oxygen inhalation at two liters per minute through nasal cannula as needed.
During an observation on 8/27/24 at 12:05 p.m., Resident 23 was lying in bed on a high Fowler position (upper body raised between 60 and 90 degrees). Resident 23 had an ongoing oxygen inhalation at three liters per minute through nasal cannula.
During an observation on 8/28/24 at 8:35 a.m., Resident 23 was lying in bed on a high Fowler position. Resident 23's oxygen inhalation was at three liters per minute through nasal cannula. Registered Nurse 4 (RN 4) was present in Resident 23's room. RN 4 also observed Resident 23's oxygen flow rate was at three liters per minute. Resident 23's oxygen flow rate was still at three liters per minute on 8/28/24 at 3:45 pm.
During a concurrent interview and record review on 8/28/24 at 3:48 p.m., RN 4 stated he made rounds on 8/28/24 at approximately 7:15 a.m. RN 4 was aware Resident 23 had a physician order of two liters of oxygen per minute through nasal cannula whenever necessary for shortness of breath. RN 4 stated he did not check Resident 23's oxygen flow rate because he thought Resident 23 was alert and Resident 23 should know her oxygen flow rate. RN 4 stated when Resident 4 gets more oxygen than Resident 4's body needs, it could slow the resident's breathing and heart rate to a dangerous level due to oxygen toxicity (breathing in too much extra [supplemental] oxygen.
During a review of the facility's policy and procedures (P&P) titled, Oxygen Administration, dated October 2010, the P&P indicated oxygen therapy was to be administered as ordered by the physician for safe oxygen administration.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 26's AR, the AR indicated Resident 26 was admitted to the facility on [DATE] with diagnoses that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 26's AR, the AR indicated Resident 26 was admitted to the facility on [DATE] with diagnoses that included hemiplegia ( paralysis on one side of the body), hemiparesis (weakness on one side of the body) and functional quadriplegia (a condition that causes complete immobility due to severe physical disability or frailty).
During a review of Resident 26's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/19/2024, the MDS indicated Resident 26 had severely impaired cognition (ability to understand) and totally dependent (helper did all of the effort, resident did none of the effort) with eating, oral hygiene and toileting hygiene, shower, upper and lower body dressing, and personal hygiene.
During a review of Resident 26's Order Summary Report (OSR) dated 8/1/2024, the OSR indicated an order for bilateral half side rails up as enabler for bed mobility and positioning three times a day for Resident 26.
During a concurrent observation and interview on 8/28/2024 at 11:57 am with Licensed Vocational Nurse 6 (LVN 6) inside Resident 26's room, Resident 26 was lying in bed on her back and bilateral upper side rails were up. Resident 26 was on low bed. LVN 6 stated Resident 26 was confused.
During a concurrent interview and record review on 8/28/2024 at 12:38 pm with LVN 6, Resident 26's medical records (chart) and PointClickCare (PCC, a cloud-based software used in long-term and post-acute care facilities) were reviewed. LVN 6 stated there were no documentation recorded that alternatives were used prior to the application or installation of siderails, and a bedrail/siderail assessment and consent was obtained prior to the use of siderails.
During an interview on 8/28/2024 at 4:26 pm with the Director of Nursing (DON), the DON stated bedrails or siderails would only be applied after all available alternatives were exhausted and failed. The DON stated, a physician's order, bedrail assessment and consent should be obtained/completed because of risks of entrapment and injury to the resident.
During a review of the facility's Policy and Procedure (P&P) titled, Proper Use of Side rails, revised December 2016, the P&P indicated, An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks.
Based on observation, interview and record review, the facility failed to attempt the use of appropriate alternatives to bed rails before its installation for two of two sampled residents (Residents 26 and 191).
These deficient practices placed Residents 26 and 191 at risk for entrapment and injury from the use of bed rails.
Findings:
a. During a review of Resident 191's admission Record (AR), the AR indicated the facility readmitted the resident on 5/7/24, with diagnoses that included diabetes mellitus (a condition that happens when the blood sugar [glucose] is too high) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe).
During an observation and concurrent interview on 8/27/24 at 11:14 a.m., Resident 191 was lying on his back in bed with one fourth length bed rails up on both sides. Resident 191 was alert and coherent. Resident 191 stated his bed rails were up since a staff (unidentified) transferred him to room [ROOM NUMBER] from the subacute care unit (provides more intensive care) of the facility. Resident 191 stated he did know why his bed rails were always up.
During a concurrent interview and record review on 8/29/24 at 3:57 p.m., Registered Nurse 5 (RN 5) stated Resident 191's medical record did not contain information that appropriate alternatives to bed rails were attempted before bed rails were used for Resident 191. The Charge Nurse (unidentified) was responsible to ensure bed rails were not used on admission and/or transfer of a resident to a different unit of the facility until appropriate alternatives were done and the resident was evaluated why appropriate alternatives did not meet the needs of the resident. RN 5 stated appropriate alternatives to bed rails included bed rails, concave mattress, foam bolsters and roll guards. RN 5 stated bed rails are accident hazard that could cause serious injury and/or death when the resident's head or limb was entraped in between the open space of the mattress or bed rails.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility staff failed to respond to the call light and address residents' needs and requests for assistance with toileting and activities of daily living (ADL...
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Based on interview and record review, the facility staff failed to respond to the call light and address residents' needs and requests for assistance with toileting and activities of daily living (ADL) in a timely manner for three of six sampled residents.
This deficient practice had the potential to negatively affect the residents' quality of life and their feelings of self-worth.
Findings:
During a Resident Council Meeting on 8/28/2024 at 10:34 am with six cognitively intact residents, three residents felt they did not get the care they needed without waiting a long time and stated staff took too long to answer the call lights. The residents stated they had to wait 10 minutes to one hour to receive assistance when using their call light to request to be changed, had their bed changed or when requesting water to drink. One resident stated, during last week (unable to determine the date), the resident's call light needed to be rung three times before any staff would come and waited 10 to 15 minutes to be changed or requested water. The resident was upset and stated, the staff were on their phone or talking to their friends and failed to pay attention to the call lights. Another resident stated, he waited up to 30 minutes about a month ago for assistance with personal hygiene and had his bed changed. Another resident stated, last week (unable to determine the date) and previous times (unspecified) it has taken up to one hour to get assistance to change the bed or for water pitcher refill.
During an interview on 8/30/2024 at 9:47 am with Certified Nurse Assistant 8 (CNA 8), CNA 8 stated when a resident requires help, they use their call light to ask for assistance or the staff member they require. CNA 8 stated, call lights should be answered as soon as possible and was unaware of a specific time call lights needed to be answered within.
During an interview on 8/30/2024 at 9:47 am with Certified Nurse Assistant 9 (CNA 9), CNA 9 stated sometimes CNA 9 was busy caring for a resident when another resident calls for assistance. CNA 9 stated, CNA 9 had to finish with the first resident's care before attending to the next resident. CNA 9 stated he tried to answer call lights quickly and was unaware of how soon call lights should be answered.
A review of the facility's Policy and Procedure (P&P) titled Call System, Resident, dated September 2022, the P&P indicated, residents are provided with a means to call staff for assistance through a communication system that directly call a staff member or a centralized work station can each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. The P&P indicated, calls for assistance are answered as soon as possible, but no later than five minutes with urgent requests for assistance being addressed immediately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were administered safely, in a time...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were administered safely, in a timely manner, and as prescribed to meet the therapeutic needs for 16 of 18 sampled residents (Residents 26, 29, 50, 57, 59, 114, 138, 148, 171, 177, 187, 319, 320, 321, 56, and 569) by failing to ensure:
1. Resident 187, with a diagnosis of dialysis was administered sevelamer (Brands: Renvela and Renagel, to lower the amount of phosphorus in the blood of patients with chronic kidney disease [CKD] who are on dialysis [medical treatment to clean the blood when the kidneys are not working properly]) received the medication with meals and did not receive doses of sevelamer late (over an hour from the scheduled administration time), on 8/13/2024, 8/14/2024, 8/16/2024, 8/17/2024, 8/18/2024, 8/20/2024, 8/21/2024, 8/22/2024, 8/24/2024, 8/25/2024, 8/26/2024, and 8/27/2024, or too close to or at the same time as the next scheduled dose on 8/14/2024, 8/20/2024, 8/24/2024, and 8/27/2024.
2. Residents 26, 29, 50, 57, 59, 114, 138, 148, 171, 177, 319, 320, 321, 56, and 569 received 9 am medications within an hour of the scheduled administration time to meet the needs of each resident.
These deficient practices had the potential to increase the risk of adverse drug reactions for Residents 26, 29, 50, 57, 59, 114, 138, 148, 171, 177, 187, 319, 320, 321, 56, and 569, and placed the residents for potential medical complications that could lead to a decline in the residents' health condition, harm, or hospitalization.
Cross Reference F759
Findings:
1. During a review of Resident 187's admission Record (AR, a document containing diagnostic and demographic information), the AR indicated Resident 187 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidneys have lost their ability to filter waste from the blood), dependence on renal dialysis (a medical treatment to clean the blood when the kidneys are not working properly), personal history of sudden cardiac arrest (a medical emergency when the heart stops beating suddenly), and hypertension (high blood pressure).
During a review of Resident 187's Minimum Data Set (MDS, a comprehensive resident assessment tool), dated 7/28/2024, the MDS indicated Resident 187 had intact cognition (ability to understand and process information).
During a review of Resident 187's Physician Order (PO), dated 7/22/2024, the PO was clarified on 7/31/2024 and started on 8/1/2024, the PO indicated Resident 187 had an order for sevelamer 800 milligrams (mg., unit of measure) to give 800 mg, one tablet by mouth three times a day with meals at 7 am, 12 pm, and 5 pm daily.
During a review of Resident 187's Medication Administration Record (MAR, a record of all medications a resident [in general] received) and Administration Details Summary/Administration History (ADS) dated 8/2024, the MAR indicated Resident 187 was administered 800 mg, 1 (one) tablet three times a day from 8/1/2024 through 8/26/2024 and two times on 8/27/2024.
During a review of Resident 187's MAR and ADS indicated the resident was administered sevelamer between 8/13/2024 through 8/27/2024 late, or more than an hour from the scheduled administration time, and/or without meals as ordered, and/or close to or at the same times as the next scheduled dose of sevelamer as follow on:
8/13/2024, scheduled for 7 am administration time, documented as administered at 8:48 am.
8/14/2024, scheduled for 7 am administration time, documented as administered at 5:29 pm.
8/14/2024, scheduled for 12 pm administration time, documented as administered at 5:31 pm.
8/14/2024, scheduled for 5 pm administration time, documented as administered at 6:18 pm.
8/16/2024, scheduled for 7 am administration time, documented as administered at 8:46 am.
8/17/2024, scheduled for 7 am administration time, documented as administered at 8:49 am.
8/18/2024, scheduled for 7 am administration time, documented as administered at 9:32 am.
8/20/2024, scheduled for 7 am administration time, documented as administered at 12:23 pm.
8/20/2024, scheduled for 12 pm administration time, documented as administered at 12:23 pm.
8/21/2024, scheduled for 7 am administration time, documented as administered at 10:20 am.
8/22/2024, scheduled for 7 am administration time, documented as administered at 10:16 am.
8/24/2024, scheduled for 7 am administration time, documented as administered at 10:09 am.
8/24/2024, scheduled for 12 pm administration time, documented as administered at 11:23 am.
8/25/2024, scheduled for 7 am administration time, documented as administered at 9:19 am.
8/26/2024, scheduled for 7 am administration time, documented as administered at 8:30 am.
8/27/2024, scheduled for 7 am administration time, documented as administered at 1:53 pm.
8/27/2024, scheduled for 12 pm administration time, documented as administered at 1:53 pm.
During a concurrent interview and record review on 8/27/2024 at 4:09 pm, with Registered Nurse Supervisor 4 (RN 4) at Nursing Station 4, Resident 187's PO for sevelamer and the MAR and ADS, dated August 2024 were reviewed. Resident 187's PO indicated to administer sevelamer 800 mg by mouth three times a day with meals. RN 4 stated, licensed nurses documented the administration of Resident 187's sevelamer incorrectly and the administrations were documented late. RN 4 stated licensed nurses should not give medication that is ordered to be administered with meals on an empty stomach, because specific medications may be harmful to the resident. RN 4 stated Resident 187's kidney function could be worsened, and result in a buildup of phosphorus in the blood which could be toxic to the resident. RN 4 stated Resident 187's sevelamer order indicated to administer with meals. RN 4 stated medications scheduled to be administered with meals are automatically to be administered with breakfast, lunch, and dinner and the meals at the facility are scheduled as breakfast at 7 am, lunch at 12 pm, and with dinner at 5 pm daily. RN 4 stated the licensed nurses are supposed to initial on the MAR to document administration at the time the medication was administered.
During an interview on 8/28/24, at 3:48 pm, with Resident 187 inside of resident's room. Resident 187 stated the resident goes to dialysis three times a week and the resident feels nausea, upset stomach, and dizziness. Resident 187 stated the resident eats breakfast in the mornings between 6:30 am to 7 am.
During a concurrent interview and record review on 8/29/2024 at 12:30 pm, with the Director of Nursing (DON), Resident 187's PO for sevelamer, the MAR and ADS dated August 2024 were reviewed. The DON stated Resident 187 should not been administered two doses of sevelamer within one hour of each other. The DON stated Resident 187's sevelamer must be administered with meals because the medication works to bind with the phosphorus in the food and prevent phosphorus from building up in the resident's blood stream. The DON stated that high levels of phosphorus cause hyperphosphatemia (too much phosphate in your blood), worsen kidney function or kidney failure, increase risk for bone weakness, and other health issues.
2. During a review of Resident 26's AR, the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (CVA, also known as a stroke, when the blood supply to part of the brain is blocked or reduced) affecting right dominant side and hypertensive heart disease (complications of high blood pressure that affect the heart).
During a review of Resident 26's MDS dated [DATE], the MDS indicated Resident 26 had severe impaired cognitive skills.
A review of Resident 26's PO, dated August 2024, the PO indicated Resident 26 scheduled for 9 am medication administration included:
a. Acidophilus oral capsule (lactobacillus), give one capsule by mouth two times a day for dietary supplement, order date 8/1/2024.
b. Aspirin 81 mg tablet, give one tablet by mouth in the morning for CVA Prophylaxis, order date 8/10/2024.
c. Docusate sodium oral tablet 100 mg, give two tablet one time a day for bowel management. Hold for loose stools, order date 8/1/2024.
d. Magnesium oxide 400 mg tablets, give one tablet by mouth three times a day (9 am, 1 pm, and 5 pm) for supplement, order date 8/1/2024.
e. Multivitamins with minerals, give one tablet by mouth one time a day for supplement, order date 8/1/2024.
f. Lisinopril 20 mg, give one tablet by mouth two times a day (9 am and 5 pm). Hold if systolic blood pressure (SBP, the pressure in the arteries when the heart contracts and pumps blood into the body, normal range is less than 120 millimeters of mercury [mmHg, a unit of measurement]) is less than 100 mmHg or apical pulse (a pulse point on the chest that reflects the heart's rhythm and function) less than (<) 60 beats per minute (bpm, normal adult range is 60 - 100 bpm) for hypertension, order date 8/1/2024.
During a medication pass observation on 8/27/2024 between 10:31 AM to 11:04 AM, with a RN 1 at Station 5, RN 1 was observed preparing and administering medications to Resident 26. The following medications was observed prepared for administration to Resident 26:
a. Acidophilus lactobacilli probiotic (500 million), one tablet.
b. Aspirin 81 mg, one tablet.
c. Docusate Sodium (used to treat constipation) 100 mg, one tablet.
d. Magnesium Oxide (used as an antacid or laxative) 400 mg, one tablet.
e. One Daily multivitamin with Minerals (vitamin supplement), one tablet.
f. Lisinopril (treat high blood pressure) 20 mg, one tablet.
During an interview on 8/27/2024 at 11:08 am, with RN 1 at Nursing Station 5, RN 1 stated Resident 26 morning medications was scheduled for 9 am and was administered today, (8/27/2024) at 11 am. RN 1 stated she ran behind passing medications partially due to a computer was not working. RN 1 stated there are more residents that had not receive the 9 am morning medications.
During an interview on 8/27/2024 at 11:44 am, with RN 1 at Nursing Station 5, RN 1 stated the RN Supervisor knew that there was a problem with the morning medication pass. RN 1 stated RN 1 is continued to pass morning medications that were scheduled for 9 am administration.
During an interview on 8/27/2024 at 11:48 am, with RN 6 at Nursing Station 4, RN 6 stated she was aware that RN 1 had computer problems this morning (8/27/2024) around 7:30 am and did not have a chance to check back on RN 1 to see if the problem was resolved. RN 6 stated that she was not aware that RN 1 was still passing morning medications that was scheduled for 9 am administration. RN 6 stated the late morning medication pass placed residents at risk for medication errors, and the potential to change in the residents' condition because the residents were not receiving medications as scheduled.
During an interview on 8/27/2024 at 1:31 PM, with Licensed Vocational Nurse 9 (LVN 9) at Nursing Station 6, LVN 9 stated that today she finished 9 am scheduled medication at 11:30 am. LVN 9 stated, That is the time I usually finish morning medication pass. LVN 9 stated licensed nurses are supposed to finish 9 am scheduled medication administration by 10 am. LVN 9 stated that supervisor was not made aware that she was running late on medication pass today (8/27/2024) because it is usual that we run behind passing medications.
During an interview on 8/28/2024 at 11:08 am, with the DON, the DON stated that she was made aware after the fact that at Station 5, 15 Residents (Residents 26, 569, 319, 57, 50, 320, 321, 516, 59, 148, 114, 171, 138, 29, and 177) received their 9 am scheduled medications late (over an hour after scheduled administration time) yesterday (8/27/2024) as follow:
3. During a review of Resident 569's AR, the AR indicated Resident 569 was admitted to the facility on [DATE] with diagnoses that included Type II diabetes (DM, a group of disease that result in too much sugar in the blood), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and hypertension.
During a review of Resident 569's History and Physical (H&P, the initial clinical evaluation and examination of an individual to include a medical history), dated 8/22/2024, the H&P indicated Resident 569 is unable to make complex medical decisions.
During a review of Resident 569's August 2024 MAR, the MAR indicated Resident 569 scheduled 9 am medication on 8/27/2024:
a. Diltiazem 60 mg, one tablet by mouth four times a day (9 am, 12 pm, 5 pm, and 9 pm) for hypertension. Hold for SBP less than 110 mmHg, heart rate less than 60 bpm, order dated 8/21/2024.
b. Amiodarone 200 mg, give one tablet by mouth in the morning for hypertension. Hold for SBP less than 110 mmHg, heart rate less than 60 bpm, order dated 8/24/2024.
c. Klor-Con (potassium) extended release (long acting) 10 milliequivalents (mEq, units of measure), give two tablets (20 mEq) by mouth in the morning for supplement, order dated 8/24/2024.
d. Metoprolol tartrate 25 mg, give one-half (12.5 mg) tablet by mouth in the morning for hypertension. Hold for SBP less than 110 mmHg, heart rate less than 60 bpm, order dated 8/22/2024.
e. Multivitamin with minerals, give one tablet by mouth in the morning for supplement, ordered date 8/23/2024.
f. Vitamin D3 25 micrograms (mcg, unit of measure), give one tablet by mouth in the morning for supplement, order date 8/23/2024.
g. Pradaxa (a blood thinner used to prevent and treat blood clots) 150 mg, give one tablet by mouth two times a day for deep vein thrombosis (DVT, a condition that occurs when a blood clot forms in a deep vein, usually in the leg or thigh) prophylaxis, order date 8/22/2024.
4. During a review of Resident 320's AR, the AR indicated Resident 320 was admitted to the facility on [DATE] with diagnoses that included Type II DM, acute kidney failure (when the kidneys suddenly can no longer filter waste products from the blood), and hypertension.
During a review of Resident 320's MDS, dated [DATE], the MDS indicated Resident 320 had intact cognition.
During a review of Resident 320's MAR, dated August 2024, the MAR indicated Resident 320 scheduled 9 am medication on 8/27/2024 included:
a. Heparin (medication used to prevent blood clots from forming) Injection Solution 5000 units, inject 5000 units subcutaneously (under the skin) every 12 hours for DVT prophylaxis, order dated 8/1/2024.
b. Metformin 500 mg, give one tablet by mouth two times a day for DM, order dated 8/1/2024.
c. Zinc Sulfate, give one tablet by mouth one time a day for healing support for one month, order dated 8/9/2024.
d. Vitamin C 500 mg, give one tablet by mouth one time a day for healing support for one month, order dated 8/9/2024.
e. Multivitamin with minerals, give one tablet by mouth in the morning for supplement, ordered date 8/1/2024.
5. During a review of Resident 319's AR, the AR indicated Resident 319 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Type II DM, epilepsy (a chronic brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain), and hypertension.
During a review of Resident 319's MDS, dated [DATE], the MDS indicated Resident 320 had intact cognition.
During a review of Resident 319's H&P and physician progress notes dated 8/5/2024, timed at 10:38 am, the H&P indicated, Resident 319 is unable to make complex medical decisions. Resident 319'physician's progress notes indicated, During her stay at SNF (Skilled Nursing Facility), she developed breakthrough seizure on and off but not frequent .She developed several breakthrough seizures (4 per record) while in bed on 7/29/24 and was sent to (general acute care hospital [GACH] emergency room [ER]) .Oxcarbazepine dose was increased from 300 mg twice a day to 450 mg twice a day . She was discharged back to SNF on 8/3/2024 .Seizure precaution and monitor. Also watch the side effects of medications.
During a review of Resident 319's MAR, dated August 2024, the MAR indicated Resident 319 scheduled 9 am medication on 8/27/2024 included:
a. Gabapentin 100 mg, give one capsule by mouth two times a day for neuropathy (nerve pain), order dated 8/6/2024.
b. Oxcarbazepine 300 mg, give one and one-half (450 mg) by mouth two times a day for seizure, order dated 8/6/2024.
c. Levetiracetam 500 mg, give three tablets (1500 mg) by mouth two times a day for seizure, order dated 8/6/2024.
d. Vitamin C 500 mg, give one tablet by mouth one time a day for healing support for one month, order dated 8/9/2024.
e. Multivitamin with minerals, give one tablet by mouth in the morning for supplement, ordered date 8/1/2024.
f. Aspirin 81 mg, one tablet by mouth one time a day for CVA prophylaxis, order date 8/3/2024.
g. Metoprolol Tartrate 6.25 mg, give one tablet by mouth one time a day for hypertension. Hold for SBP less than 110 mmHg, heart rate less than 60 bpm, order dated 8/3/2024.
6. During a review of Resident 57's AR, the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses that included Type II DM, acute kidney failure, and hypertension
During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57 had moderately impaired cognition.
During a review of Resident 57's MAR, dated August 2024, the MAR indicated Resident 57 scheduled 9 am medication on 8/27/2024 included:
a. Gabapentin 300 mg, give one capsule by mouth two times a day for neuropathy. Hold if patient is drowsy or has blurry vision, order dated 8/1/2024.
b. Duloxetine 20 mg, give one capsule by mouth one time a day for depression manifested by feeling hopeless, order dated 8/1/2024.
7. During a review of Resident 50's AR, the AR indicated Resident 50 was admitted to the facility on [DATE] with diagnoses that included epilepsy and hypertension.
During a review of Resident 50's MDS, dated [DATE], the MDS indicated Resident 50 had intact cognition.
During a review of Resident 50's MAR, dated August 2024, the MAR indicated Resident 50 scheduled 9 am medication on 8/27/2024 included:
a. Amlodipine 10 mg, one tablet by mouth in the morning for hypertension, order dated 8/1/2024.
b. Levetiracetam 1000 mg, give one tablet (1000 mg) by mouth two times a day for seizure disorder, order dated 8/1/2024.
8. During a review of Resident 321's AR, the AR indicated Resident 321 was admitted to the facility on [DATE] with diagnoses that include Type II DM, CKD, and hypertension.
During a review of Resident 321's MDS, dated [DATE], the MDS indicated Resident 321 had intact cognition.
During a review of Resident 321's MAR, dated August 2024, the MAR indicated Resident 321 scheduled 9 am medication on 8/27/2024 included an order for amlodipine 5 mg, give 1 tablet by mouth in the morning for hypertension, order dated 8/6/2024.
9. During a review of Resident 56's AR, the AR indicated Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia, CKD, history of falling, and hypertension.
During a review of Resident 56's MDS, dated [DATE], the MDS indicated Resident 56 had moderately impaired cognition.
During a review of Resident 56's MAR, dated August 2024, the MAR indicated Resident 56 scheduled 9 am medication on 8/27/2024 included:
a. Memantine 5 mg, give one tablet by mouth two times a day for dementia (a loss of brain function that affects a person's ability to think, remember, and make decisions), order dated 8/1/2024.
b. Metoprolol Tartrate 50 mg, one tablet by mouth every 12 hours for hypertension, order dated 8/1/2024.
c. Pradaxa 75 mg, give one capsule by mouth two times a day for DVT prophylaxis, order dated 8/2/2024.
10. During a review of Resident 59's AR, the AR indicated Resident 59 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included epilepsy, dementia, and asthma (difficulty breathing).
During a review of Resident 59's MDS, dated [DATE], the MDS indicated Resident 59 had intact cognition.
During a review of Resident 59's MAR, dated August 2024, the MAR indicated Resident 59 scheduled 9 am medication on 8/27/2024 included:
a. Bupropion 75 mg, give one tablet by mouth one time a day for major depressive disorder manifested by lack of interest in activities and hot flashes, order dated 8/1/2024.
b. Lisinopril 5 mg, give one tablet by mouth one time a day for hypertension, order dated 8/1/2024.
c. Venlafaxine ER (extended release) 24 hours 75 mg, give one capsule by mouth one time a day for depression manifested by verbalization of sadness, order dated 8/1/2024.
d. Carbamazepine ER 12 hours 200 mg, give one tablet by mouth two times a day for seizure disorder, order dated 8/1/2024.
11. During a review of Resident 148's AR, the AR indicated Resident 148 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included epilepsy and hypertensive heart disease (includes complications of high blood pressure that affect the heart).
During a review of Resident 148's MDS, dated [DATE], the MDS indicated Resident 148 had moderately impaired cognition.
During a review of Resident 148's MAR, dated August 2024, the MAR indicated Resident 148 scheduled 9 am medication on 8/27/2024 included:
a. Famotidine 20 mg, give one tablet by mouth every 12 hours for Gastroesophageal reflux disease (GERD, a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach), order dated 8/1/2024.
b. Keppra 1000 mg, give one tablet by mouth two times a day for seizure disorder, order dated 8/1/2024.
12. During a review of Resident 114's AR, the AR indicated Resident 114 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia, Type II DM, dementia, and hypertensive heart disease.
During a review of Resident 114's MDS, dated [DATE], the MDS indicated Resident 114 had severely impaired cognition.
During a review of Resident 114's MAR, dated August 2024, the MAR indicated Resident 114 scheduled 9 AM medication on 8/27/2024 included:
a. Clopidogrel 75 mg, give one tablet by mouth one time a day for thrombocytosis (having too many platelets in the blood), order dated 8/1/2024.
b. Famotidine 20 mg, give one tablet by mouth one time a day for GERD, order dated 8/1/2024.
c. Fenofibrate 134 mg capsule, one capsule by mouth one time a day for high cholesterol, order dated 8/1/2024.
d. Finasteride 5 mg, one tablet by mouth one time a day for Benign prostatic hyperplasia (BPH, age-associated prostate gland enlargement that can cause urination difficulty), order dated 8/1/2024.
e. Losartan 100 mg, give one tablet by mouth one time a day for hypertension, order dated 8/1/2024.
f. Metformin 1000 mg, give one tablet by mouth two times a day for DM, Give with food, order dated 8/1/2024.
13. During a review of Resident 171's AR, the AR indicated Resident 171 was admitted to the facility on [DATE], no diagnoses were included on Resident 171's AR.
During a review of Resident 171's MDS, dated [DATE], the MDS indicated Resident 171 had severely impaired cognition.
During a review of Resident 171's MAR, dated August 2024, the MAR indicated Resident 171 scheduled 9 am medication on 8/27/2024 included:
a. Bisoprolol (treat high blood pressure) 10 mg, one tablet via gastrostomy tube (G-tube, a medical device that allows for the delivery of nutrition, fluids, and medications directly into the stomach) one time a day, order dated 8/15/2024.
b. Omeprazole 20 mg, give via G-tube in the morning for GERD, order dated 8/15/2024.
c. Apixaban (blood thinner) 2.5 mg, give via G-tube two times a day prophylaxis for DVT.
d. Losartan 25 mg, give via G-tube two times a day for hypertension, order dated 8/15/2024.
14. During a review of Resident 138's AR, the AR indicated Resident 138 was admitted to the facility on [DATE], with diagnoses that included hypertensive heart disease and respiratory failure (difficulty breathing).
During a review of Resident 138's MDS, dated [DATE], the MDS indicated Resident 138 had severely impaired cognition.
During a review of Resident 138's MAR, dated August 2024, the MAR indicated Resident 138 scheduled 9 am medication on 8/27/2024 included:
a. Aspirin 81 mg, one tablet by mouth one time a day for CVA prophylaxis, order dated 8/1/2024.
b. Labetalol 100 mg, give one tablet by mouth two times a day for hypertension, order dated 8/1/2024.
15. During a review of Resident 29's AR, the AR indicated Resident 29 was admitted to the facility on [DATE], with diagnoses that included hypertensive heart disease, Type II DM and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side
During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29 had severely impaired cognition.
During a review of Resident 29's MAR, dated August 2024, the MAR indicated Resident 29 scheduled 9 am medication on 8/27/2024 included:
a. Memantine 10 mg, give one tablet by mouth two times a day for dementia order dated 8/1/2024.
b. Aspirin 81 mg, give one tablet by mouth one time a day for CVA prophylaxis, order dated 8/1/2024.
16. During a review of Resident 177's AR, the AR indicated Resident 177 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included end stage renal disease, respiratory failure, dependence on renal dialysis, epilepsy, and hypoglycemia (low blood sugar).
During a review of Resident 177's MDS, dated [DATE], the MDS indicated Resident 177 had severely impaired cognition.
During a review of Resident 177's MAR, dated August 2024, the MAR indicated Resident 177 scheduled 9 am medication on 8/27/2024 included:
a. Atenolol 25 mg, give one tablet via G-tube one time a day for hypertension, order dated 8/16/2024.
b. Gabapentin 100 mg, give one capsule via G-tube one time a day for neuropathy, order dated 8/2/2024.
c. Levetiracetam Oral Solution 100 mg/ml, give 5 ml (500 mg) via G-tube every 12 hours for seizure disorder, order dated 8/1/2024.
During an interview on 8/29/2024 at 12:46 PM, with the DON, the DON stated that she was aware that residents at Nursing Station 4, Nursing Station 5, and Nursing Station 6 were receiving medications late and/or administered incorrectly which could cause harm to the residents especially if given late or too close to another scheduled dose. The DON stated that she began looking at residents at Nursing Station 5 but have not begun looking at residents throughout the facility for similar concerns.
A review of the facility's P&P titled, Administering Medications, dated 4/2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame. Medication Administration Record times are determined by resident need and benefit, not staff convenience .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
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 medication error rate was less than five perce...
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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 medication error rate was less than five percent (%). Six medication errors out of 28 total opportunities contributed to an overall medication error rate of 21.43 % for two of four residents (Residents 26 and 187) observed during medication administration (MedPass).
a. For Resident 26, the facility failed to ensure Resident 26 received medications within an hour of the administration time to meet the resident's therapeutic needs.
b. For Resident 187, the facility failed to ensure Resident 187's order for sevelamer (Brands: Renvela and Renagel, to lower the amount of phosphorus in the blood of patients with chronic kidney disease [CKD] who are on dialysis [medical treatment to clean the blood when the kidneys are not working properly]) was administered with meals in accordance with the physician orders and manufacturer's specification.
These deficient practices had the potential for Residents 26 and 187 to experience adverse reactions, medical complications, that could lead to a decline in residents' condition, harm, or hospitalization.
Cross Reference F755
Findings:
a. During a review of Resident 26's admission Record (AR, a document containing diagnostic and demographic information), the AR indicated Resident 26 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (CVA, also known as a stroke, when the blood supply to part of the brain is blocked or reduced) affecting right dominant side and hypertensive heart disease (complications of high blood pressure that affect the heart).
During a review of Resident 26's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/19/2024, the MDS indicated the resident's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making was severely impaired. Resident 26's MDS indicated the resident was totally dependent upon facility staff assistance for all activities of daily living.
During a review of Resident 26's Medication Administration Record (MAR), dated August 2024, indicated Resident 26 orders scheduled for 9 am administration included:
1. Acidophilus oral capsule (lactobacillus), give one capsule by mouth two times a day for dietary supplement, order date 8/1/2024
2. Aspirin 81 milligram (mg, unit of measure) tablet, give one tablet by mouth in the morning for CVA Prophylaxis, order date 8/10/2024
3. Docusate sodium oral tablet 100 mg, give two tablets one time a day for bowel management. Hold for loose stools, order date 8/1/2024.
4. Magnesium oxide 400 mg tablet, give one tablet by mouth three times a day (9 am, 1 pm, and 5 pm) for supplement, order date 8/1/2024.
5. Multivitamins with minerals, give one tablet by mouth one time a day for supplement, order date 8/1/2024.
6. Lisinopril 20 mg, give one tablet by mouth two times a day (9 am and 5 pm). Hold if systolic blood pressure (SBP, the pressure in the arteries when the heart contracts and pumps blood into the body, normal range is less than 120 millimeters of mercury [mmHg, a unit of measurement]) is less than 100 mmHg or apical pulse (a pulse point on the chest that reflects the heart's rhythm and function) less than (<) 60 beats per minute (bpm, normal adult range is 60 - 100 bpm) for hypertension, order date 8/1/2024.
During a medication Pass Observation on 8/27/2024 between 10:31 am to 11:04 am, with a Registered Nurse Supervisor 1 (RN) 1 at Station 5, RN 1 was observed preparing and administering medications for Resident 26. The following medications was observed prepared for administration to Resident 26:
1. Acidophilus lactobacilli probiotic (500 million), one tablet
2. Aspirin 81 mg, one tablet
3. Docusate Sodium (used to treat constipation) 100 mg, one tablet
4. Magnesium Oxide (used as an antacid or laxative) 400 mg, one tablet
5. One Daily MVI with Minerals (vitamin supplement), one tablet
6. Lisinopril (treat high blood pressure) 20 mg, one tablet
During an interview on 8/27/2024 at 11:08 am, with RN 1 at Nursing Station 5, RN 1 stated Resident 26 morning medications was scheduled for 9 am and was administered today, 8/27/2024 at 11 am. RN 1 stated she ran behind the medication pass schedule partially due to the computer was not working.
During an interview on 8/27/2024 at 11:48 am, with RN 6, RN 6 stated she was aware that RN 1 had computer problems in the morning around 7:30 am but was not aware that RN 1 was still passing medications scheduled for 9 am administration time after 11 am today (8/27/24) and had not followed up with RN 1. RN 6 stated medications are supposed to be passed and administered to residents within two hours, an hour before and up to an hour after the scheduled administration time of 9 am. RN 6 stated medication errors could cause a resident (Resident 26) to experience a change of condition because the residents are not receiving the medications as scheduled or too close together.
b. During a review of Resident 187's AR, the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidneys have lost their ability to filter waste from the blood), dependence on renal dialysis (a medical treatment to clean the blood when the kidneys are not working properly), personal history of sudden cardiac arrest (a medical emergency when the heart stops beating suddenly), and hypertension (high blood pressure).
During a review of Resident 187's MDS, dated [DATE] indicated the resident's cognitive skills for daily decision-making was intact. Resident 187's MDS indicated the resident required set up or clean-up assistance for eating, supervision, or touch assistance for oral hygiene, and substantial to total dependence on staff assistance with activities of daily living (bed mobility, transfer in and out of bed to chair or wheelchair, dressing, toileting, personal hygiene).
During a review of Resident 187's Physician's Orders dated 7/22/2024, indicated Resident 187 active orders for August 2024 included:
1. Sevelamer (medication used to control high blood levels of phosphorus) oral tablet 800 mg, give one tablet by mouth three times a day with meals for Supplement
2. Allopurinol (a medication used to prevent or lower high uric acid [a waste product left over from normal chemical processes in the body and found in the urine and blood] levels in the blood) oral tablet 100 mg, give one tablet by mouth one time a day for Gout (joint pain and inflammation/swelling)
3. Amiodarone (a medication that prevents and treats arrhythmia, a fast or irregular heartbeat) oral tablet 200 mg, give o tablet by mouth every 12 hours for atrial fibrillation (irregular heartbeat). Hold for SBP less than 110 mmHg.
4. Aspirin 81 mg, oral tablet delayed release (Aspirin), give one tablet by mouth one time a day for CVA Prophylaxis (preventive care).
5. Colchicine (medication used to prevent or treat attacks of gout) oral capsule 0.6 mg, give one capsule by mouth one time a day for Gout.
6. Eliquis (apixaban, a blood thinner) oral tablet 6 mg, give one tablet by mouth every 12 hours for deep vein thrombosis (DVT, a serious condition that occurs when a blood clot [clumps of blood] forms in a deep vein, usually in the leg) Prophylaxis.
7. Ferrous Sulfate (iron supplement for anemia, low red blood cells or dysfunctional red blood cells in the body leading to reduced oxygen flow), oral tablet 325 mg, give one tablet by mouth two limes a day for Supplement
8. Nephro Vitamins (vitamin supplement) oral Tablet 0.8 mg, give one tablet by mouth one time a day for Supplement
9. Neurontin (gabapentin, medication used to manage seizures, a sudden rush of abnormal electrical activity in your brain; and neuropathy, damage to the nerves and/or pain) oral capsule 100 mg (Gabapentin), give one capsule by mouth two times a day for neuropathy.
10. Senna (laxative) oral tablet 8.6 mg, give one tablet by mouth two times a day for Bowel Management. Hold for Loose stool.
11 Vitamin C (vitamin supplement) oral tablet 500 mg, give one tablet by mouth one time a day for Supplement.
During a medication Pass Observation on 8/27/2024 between 9:34 am to 10 am, with a Licensed Vocational Nurse 7 (LVN 7) at Station 4, LVN 7 prepared and administered 10 out of 11 medications for Resident 187 that included, sevelamer, allopurinol, amiodarone, aspirin, colchicine, apixaban, ferrous sulfate, Nephro vitamins, gabapentin, and Vitamin C, with the laxative senna being held, not administered per Resident 187's request.
During a concurrent interview and record review on 8/27/2024 at 4:09 pm, with Registered Nurse Supervisor 4 (RN 4) at Nursing Station 4, Resident 187's physician orders and MAR for sevelamer, dated August 2024 MAR were reviewed. Resident 187's physician order for sevelamer indicated to administer sevelamer three times a day with meals. Resident 187's August Administration Detail report dated 8/27/2024, timed at 1:53 pm, indicated licensed nurses initialed and documented the same administration time for two different scheduled doses of sevelamer for Resident 187, which was scheduled for two different times (7 am and 12 pm) on 8/27/24. However, LVN 7 was observed administering Resident 187's sevelamer scheduled for 7 am at 9:55 am (almost three hours after scheduled administration time) and LVN 7 documented the administration on 8/27/2024 at 1:53 pm which was the same time the scheduled 12 pm dose of sevelamer for Resident 187 was documented as administered to the resident. RN 4 stated, that LVN 7 documented the administration of Resident 187's sevelamer incorrectly and the administrations were documented late. RN 4 stated licensed nurses should not give medication that is ordered to be administered with meals on an empty stomach, because specific medications may be harmful to the resident (Resident 187). RN 4 stated Resident 187's sevelamer order indicated to administer with meals and the meals at the facility are scheduled as breakfast at 7 am, lunch at 12 pm, and dinner at 5 pm daily. RN 4 stated the licensed nurses are supposed to initial on the MAR to document administration at the time the medication was administered.
During an interview on 8/28/24 at 3:48 pm, with Resident 187 inside of resident's room. Resident 187 stated, Resident 187 goes to dialysis three times a week and feels nausea, upset stomach, and dizziness. Resident 187 stated, the resident eats breakfast in the mornings between 6:30 am to 7 am.
A review of the manufacturer labeling for sevelamer HCl 800 mg, revised date 1/2024, indicated, Starting dose is one or two 800 mg or two to four 400 mg tablets three times per day with meals .Advise patients to take sevelamer hydrochloride tablets with meals and adhere to their prescribed diets .The most common reasons for discontinuing treatment were gastrointestinal (GI) adverse reactions. GI adverse reactions included but not limited to diarrhea, nausea, constipation, abdominal distension, and vomiting.
A review of the facility's P&P titled, Administering Medications, dated 4/2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame. Medication Administration Record times are determined by resident need and benefit, not staff convenience .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
A review of the facility's P&P titled, Administering Medications, dated 4/2019, indicated, Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
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 ensure medications were kept secure with limited acces...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were kept secure with limited access by failing to:
1. Lock the medication cart (MedCart) that contained residents' medications at Station 4 when the MedCart was not attended by a licensed nurse.
2. Ensure medications prepared for Resident 187 was secured and not left on top of the MedCart at Station 4 when the medications were outside of a licensed nurse's view.
These deficient practices had the potential for Resident 187's medications to be accessible to other unauthorized staff and residents, and increased the risk for loss of control, safety, and security of all medications.
Findings:
During a review of Resident 187's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidneys have lost their ability to filter waste from the blood), dependence on renal dialysis (a medical treatment to clean the blood when the kidneys are not working properly), personal history of sudden cardiac arrest (a medical emergency when the heart stops beating suddenly), and hypertension (high blood pressure).
During a review of Resident 187's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 7/28/2024, the MDS indicated the resident's cognitive skills for daily decision making was intact. Resident 187's MDS indicated the resident required set up or clean-up assistance for eating, supervision, or touch assistance for oral hygiene, and substantial to total dependence on staff assistance with activities of daily living (bed mobility, transfer in and out of bed to chair or wheelchair, dressing, toileting, personal hygiene).
During a review of Resident 187's physician order summary (POS), the POS, dated 7/31/2024, indicated the resident was prescribed the following morning medications:
1. Sevelamer (medication used to control high blood levels of phosphorus [present in many foods, especially processed foods] in people with chronic kidney disease who are on dialysis) oral tablet 800 milligrams (mg, unit of measure), give one tablet by mouth with meals for Supplement
2. Allopurinol (medication used to prevent or lower high uric acid [a waste product left over from normal chemical processes in the body and found in the urine and blood] levels in the blood) oral tablet 100 mg, give one tablet by mouth one time a day for Gout (joint pain and inflammation/swelling).
3. Amiodarone (medication used to prevents and treats arrhythmia, a fast or irregular heartbeat) oral tablet 200 mg, give 1 tablet by mouth every 12 hours for atrial fibrillation (irregular heartbeat). Hold for Systolic blood pressure (SBP, the pressure in the arteries when the heart contracts and pumps blood into the body, normal range is less than 120 millimeters of mercury [mmHg, a unit of measurement]) less than 110 mmHg.
4. Aspirin 81 oral tablet delayed release (Aspirin) give one tablet by mouth one time a day for cerebrovascular accident (CVA, a medical condition that occurs when blood flow to the brain is suddenly interrupted, a stroke) Prophylaxis (preventive care).
5. Colchicine (used to prevent or treat attacks of gout) Oral Capsule 0.6 MG, Give 1 capsule by mouth one time a day for Gout
6. Eliquis (a blood thinner) oral tablet 6 mg (Apixaban), give one tablet by mouth every 12 hours for deep vein thrombosis (DVT, a serious condition that occurs when a blood clot [clumps of blood] forms in a deep vein, usually in the leg) Prophylaxis.
7. Ferrous Sulfate (iron supplement used to treat anemia, low red blood cells or dysfunctional red blood cells in the body leading to reduced oxygen flow), oral tablet 325 mg, give one tablet by mouth two times a day for supplement.
8. Nephro Vitamins (vitamin supplement) oral tablet 0.8 mg, give one tablet by mouth one time a day for supplement.
9. Neurontin (medication used to manage seizures, a sudden rush of abnormal electrical activity in your brain; and neuropathy, damage to the nerves and/or pain) oral capsule 100 mg (Gabapentin), give one capsule by mouth two times a day for neuropathy.
10. Senna (laxative) oral tablet 8.6 mg, give one tablet by mouth two times a day for bowel management. Hold for loose stool.
11. Vitamin C (vitamin supplement) oral tablet 500 mg, give one tablet by mouth one time a day for supplement.
During a medication pass observation on 8/27/2024 between 9:34 am to 10 am, with a Licensed Vocational Nurse 7 (LVN 7) at Station 4, LVN 7 prepared 11 morning medications listed above for Resident 187 and carried two to three out of the 11 medications into Resident 187's room. LVN 7 left the remaining medications on top of the MedCart in the hallway. The MedCart was observed unlocked in the hallway where residents and staff passed by. LVN 7 closed Resident 187's curtain left the two to three medications at the resident's bedside for the resident to take independently. LVN 7 returned to the unlocked Medcart, took two more medications from the top of the Medcart and returned to Resident 187's beside behind the curtain to administer more medications to Resident 187. LVN 7 repeated this process of removing two or three medications from the top of the MedCart, administering the medications to Resident 187, then returning to the MedCart for more medications until Resident 187 was administered all prepared medications except the one laxative medication (senna), that Resident 187 refused at the time.
During an interview on 8/27/2024 at 12:41 pm, with LVN 7 at Station 4, LVN 7 stated, I did not lock my medication cart when I went to take his (Resident 187's) medications. LVN 7 stated I should have locked my medication cart and not left the medication cart unlocked. LVN 7 stated I should have locked the medication cart to prevent the risk of someone else going into the medication cart and taking medications. LVN 7 stated medications should not have been left unattended and out of view on the top of the medication cart. LVN 7 stated the medications should have been placed on top of a medication tray and taken all at once into Resident 187's room for medication administration to prevent another resident from grabbing the medications from the top of the medication cart when they were out of LVN 7's view. LVN 7 stated if a resident took a medication that was left on top of the medication cart or from inside of the medication cart that was not prescribed for that resident the unintended resident could have experienced adverse or allergic reactions.
During a review of the facility's Policy and Procedures (P&P) titled, Storage of Medications, dated 4/2019, the facility's P&P indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner .Unlocked medication carts are not left unattended. Only persons authorized to prepare and administer medications have access to locked medications.
During a review of the P&P titled, Administering Medications, dated 4/2019, the facility's P&P indicated, During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.
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 ensure the standardized recipes for lunch menu was followed on 8/27/2024 by failing to:
a. Ensure staff followed food product...
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Based on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 8/27/2024 by failing to:
a. Ensure staff followed food production recipes for the mechanical soft diet (diet for residents who experienced chewing or swallowing limitations, diet is modified to a soft, chopped or ground consistency) during lunch preparation and tray line observation for 33 residents on a mechanical soft diet, and received chopped roast beef with gravy instead of ground roast beef with gravy per menu and spreadsheet (food portion and serving guide.)
b. Ensure 26 residents on a pureed diet received pureed green beans instead of pureed spinach au gratin per menu.
c. Ensure one resident who was a vegetarian (Resident 220) did not complain that his meals do not have vegetarian protein options and that only starch and the vegetable of the day is served on the plate.
These deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake when the menu is not updated to reflect the needs of the resident and increased choking risk for 33 residents who were on mechanical soft diet.
Findings:
a. According to the facility lunch menu for mechanical soft diet (chopped and ground) on 8/27/2024, the following items were to be served:
1. Ground herb and spice Roast beef served with #10 scoop yielding 3 ounces (oz.),
2. Herb and spice gravy 1oz.
3. Mashed potatoes #8 scoop yielding 4 oz.
4. Spinach au gratin soft ½ cup.
5. Parsley flakes for garnish.
6. Caesar salad and dressing chop ½ inches serve ½ cup.
7. Fruit mix crumble cake and milk.
During an observation of the tray line service for lunch on 8/27/2024, at 12:15pm, residents who were on a mechanical soft diet and (chopped), the cook served roast beef that was cut into pieces or shredded in long strips instead of ground roast beef per spreadsheet (food portion and menu serving guide). Cook1 was shredding and pulling apart chunks of beef with gloved hands and the use of tongs into inconsistent sizes, varying in length. The cook was shredding while meat is on the steam table and right before plating the meat. The chopped meat was not prepared prior to service for lunch.
During a concurrent review of the spreadsheet and interview with [NAME] (Cook1) on 8/27/2024, at 1pm, Cook1 stated cooks always follow the menu and the spreadsheet when serving food. Cook1 stated residents on a mechanical soft and chopped diet means they receive chopped meat. Cook1 stated chopped meat is cut into ½ inch. Cook1 stated the chopped meat size on the steam table is not consistent in size and not all pieces are ½ inch. Cook1 verified that the spreadsheet indicates to serve ground roast beef to residents on a mechanical soft and chopped diets. Cook1 stated she made a mistake and assumed it was chopped meat. Cook1 stated if residents receive the wrong texture they have a risk of choking.
During and interview with Dietary supervisor (DS) and Registered Dietitian (RD) on 8/27/2024 at 1:05pm, the DS stated the cooks should always follow the menu and spreadsheet. The DS stated the spreadsheet indicates to serve ground roast beef. The RD stated the menu requires to serve ground roast beef to residents on a mechanical soft diet even though the diet order is mechanical soft and chopped.
During an interview with the RD and Director of Rehab program (DOR) on 8/27/2024 at 3pm, the RD stated the diet order for a mechanical soft chopped or ground diet is ordered by the Speech therapist. The RD stated the size of the meat is not indicated on the diet orders. The DOR stated resident diet orders for a mechanical soft specified ground or chopped based on the speech therapist swallowing evaluation. The DOR stated DOR did not know the facility menu indicates meat is served ground for mechanical soft diets. The DOR stated staff should follow the menu per policy.
A review of the recipe for the Herb and Spice Roast beef indicated for mechanical soft diets, to grind the beef, and serve with gravy.
A review of the facility's policy titled Regular mechanical soft diet (dated 2020) indicated, Foods such as: meats, poultry and fish are allowed when ground with meat juices, gravy or sauce and avoid whole or chopped meat. Chopped meat only allowed when ordered by speech therapist. Size of meat should be specified in diet order, such as less than ½ inch or less than 1 inch.
b. According to the facility lunch menu for puree diet on 8/27/2024, the following items will be served:
1. Pureed herb and spice roast beef.
2. Pureed gravy.
3. Mashed potatoes.
4. Pureed Spinach au gratin.
5. Pureed Caesar salad and dressing.
6. Pureed fruit mix crumble Cake.
During an observation of the tray line service for lunch on 8/27/2024, at 12:15pm, residents who were on a puree diet, the cook served pureed green beans instead of pureed spinach.
During an interview with Cook1 on 8/27/2024, at 1pm, Cook1 said some people do not like spinach and instead Cook1 served puree green beans. Cook1 stated not following the menu can make residents complain about the food.
During an interview with the DS on 8/27/2024, at 1:05pm, the DS stated DS noted there was no pureed spinach and made the pureed spinach right before lunch service and placed it on the stove behind Cook1. The DS stated Cook1 did not serve the pureed spinach to the residents. The DS stated not serving the items on the menu can make the residents dissatisfied with the meals.
A review of the facility policy titled Menu (revised October 2017) indicated, Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy.
c. During an observation of the tray line service for lunch on 8/27/2024, at 12:15pm one resident (resident 220) who was on a pureed vegetarian diet (food that is blended to a pudding consistency, no chewing required), Cook1 served only mashed potatoes and puree green beans.
During an interview with Cook1 on 8/27/2024, at 1pm, Cook1 stated there is no pureed vegetarian option today. Cook1 stated Cook1 is covering for the staff who left and is only serving what was prepared prior to Cook1 arriving.
During an interview with DS on 8/27/2024, at 1:05pm, the DS stated the resident received mashed potatoes and pureed green beans. The DS stated the resident did not receive a vegetarian protein option. The DS stated the resident did not receive all the nutrients and this can lead to weight loss.
During a concurrent interview with the RD on 8/27/2024, at 1:10pm, RD stated the facility should provide a vegetarian protein option to residents who are on vegetarian diet. The RD stated not providing enough food can lead to a decreased nutrient intake and placed the resident at risk for weight loss.
During an interview with Resident 220 and the family representative (FR1) on 8/28/2024, at 11:45am, FR1 stated that resident 220 is religious and a vegetarian but can have fish and eggs from the facility. FR1 stated the resident received mashed potatoes and puree vegetable everyday with no protein option. FR1 stated FR1 brings protein options from home to feed (resident 220) every day. FR1 is concerned that resident 220 is not receiving all the nutrients and can experience weight loss.
A review of facility policy titled Menus (revised October 2017) indicated, Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy .Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal .If a food group is missing from a resident's daily diet (example dairy products), the resident is provided an alternate means of meeting his or her nutritional needs (example calcium supplementation or fortified non-dairy alternatives.
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:
a. Ensure one resident (Resident 8) on a puree diet (foods that is blended, do not require chewing, and are easily swallowed...
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Based on observation, interview and record review, the facility failed to:
a. Ensure one resident (Resident 8) on a puree diet (foods that is blended, do not require chewing, and are easily swallowed. Food should be smooth .consistency of pudding) received cottage cheese texture in form that meet their needs when they received regular cottage cheese that was lumpy and had small to medium size cheese curds.
b. Ensure one resident (Resident 219) who was on a Mechanical soft texture chopped diet received a grilled cheese sandwich texture in form that meet their needs when the grilled cheese sandwich was dry with hard crust and was not chopped.
These deficiencies had the potential to result in decreased intake related to inconsistent texture, meal dissatisfaction and increase choking and aspiration risk.
Findings:
During an observation of meal preparation on 8/27/2024 at 12:15pm, Resident 8 who was on pureed diet, the cook served puree potato, pureed green beans and a cup of regular cottage cheese.
During a concurrent observation and interview, Cook1 stated the resident likes cottage cheese and gets it every meal instead of the meat.
During a dining observation on 8/27/2024 at 1:30pm Resident 8's family needed to mash the cottage cheese and mix with apple sauce before the resident could eat. The Family representative stated the cottage cheese is not smooth enough for Resident 8 to eat.
During an interview with the registered Dietitian (RD) and Dietary supervisor (DS) on 8/28/2024 at 1:30pm, the DS stated Resident 8's diet order indicated a pureed diet, but it is incorrect. The DS stated they follow the orders and are not aware of any diet changes. The RD stated RD will ensure orders are correct and the resident receives the diet in the form that is ordered.
During an observation of the meal preparation in the kitchen on 8/28/2024 at 12:20pm Resident 219 who was on a mechanical soft texture and chopped diet (diet for residents who experience chewing or swallowing limitations, diet is modified to a soft, chopped or ground consistency.) received a grilled cheese sandwich with crust and was not chopped.
During the same observation and interview with RD, on 8/28/2024 at 12:20pm, the RD stated if a sandwich is served on a mechanical soft diet chopped, then the sandwich must be chopped into small pieces.
During a meal observation on 8/28/2024 at 12:45pm Resident 219 stated she was very hungry and was waiting for the meal. During the same observation Resident 219 had no dentures. Resident 219 had difficulty swallowing the grilled cheese sandwich and was noted to have several sips of juice to swallow after every bite of the sandwich.
During an interview with RD and DS on 8/29/2024 at 9:30am, RD sated for a mechanical soft diet the sandwich should have been chopped into pieces and the sandwich should be soft with no crust. The RD stated Resident 219 has no dentures and should get soft foods, which should be cut so that Resident 219 is able to swallow. The DS stated DS does not know why Resident 219 received a sandwich. The DS stated resident 219 should have received the mechanical soft lunch of the day. The DS stated it is important to follow the diet order, so residents receive the correct diet and the right texture so there is no risk of any swallowing problems.
A review of the recipe for a grilled two cheese sandwich indicated a mechanical soft diet is to provide a soft grilled sandwich with no hard crusts.
A review of resident 219 speech therapy SLP evaluation and plan of treatment record dated 8/24/2024 indicated, resident requires min chewing difficulty with certain hard food; risk factors include risk for malnutrition and aspiration.
A review of Resident 8's diet order listed on the facility order listing report dated 8/27/2024 indicated CCHO (Controlled carbohydrates), NAS (no added salt) pureed texture, nectar/mildly thick for liquids.
A review of Resident 219's diet order listed on the facility order listing report dated 8/27/2024 indicated CCHO mechanical soft texture chopped diet, regular consistency for liquids.
A review of the International Dysphagia Diet Standardization Initiative guidelines for pureed diet (www.IDDSI.org) indicated, pureed food does not require chewing and must have a smooth texture with no lumps.
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 preparation practices in the kitchen by failing to:
a. Ensure one Dietary Aide (DA1...
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Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen by failing to:
a. Ensure one Dietary Aide (DA1) working in the dish machine area washed his hands and changed gloves when removing the clean and sanitized dishes from the dish machine.
b. Ensure two large packages of previously cooked, frozen, and thawed roasted turkey breast, was not stored in the refrigerator with dates of 8/22/24, which exceeded the storage period for thawed poultry.
c. Ensure food brought to residents from outside of the facility, including leftovers stored in the resident food refrigerator and kitchen freezer were dated.
These deficiencies had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 164 out of 226 residents who received food from the kitchen.
Findings:
a. During an observation in the dishwashing area on 8/27/2024 at 9:30am, Dietary Aide (DA1) was rinsing soiled dishes and loading the dirty dishes in the dish machine. DA1 had gloves on his hands and proceeded to remove the clean and sanitized dishes from the dish machine without washing his hands and replacing his gloves.
During a concurrent interview, DA1 stated he forgot to remove his gloves and wash his hands before touching the clean dishes. DA1 stated usually there are two people working in the dish area and the second staff will remove the clean dishes. DA1 stated not changing gloves and washing his hands can contaminate clean dishes and can make residents sick.
During an interview with Dietary Aide (DA2) on 8/27/2024 at 9:35am, DA2 was finishing up preparing juices and cleaning up. DA2 stated she is assigned to assist with dishwashing at 9am to assist with removing clean dishes. DA2 stated she was not finished with her work to help. DA2 stated it is important to wash her hands and replace her gloves when touching clean dishes to not contaminate the dishes.
During an interview with the Dietary Supervisor (DS) on 8/27/2024 at 9:40am, the DS stated staff should always wash their hands and replace their gloves when moving from dirty dishes to removing clean and sanitized dishes from the dish machine to prevent cross contamination of the dishes.
A review of facility policy titled, Handwashing/Hand Hygiene (revised august 2019) indicated, The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
A review of facility policy titled, Food Preparation and Service (Revised November 2022) indicated, Cross-contamination occurs when harmful substances, chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned .Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness .Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays.
A review of the 2022 U.S. Food and Drug Administration Food Code, Code 2-301.14 When to Wash. Indicated, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately E) After handling soiled EQUIPMENT or UTENSILS.
b. During an observation in the kitchen on 8/27/2024 at 9:50am, there were two large roast turkey breasts previously cooked and frozen with a thaw date of 8/22/2024 exceeding storage period for roast turkey stored in the walk-in refrigerator. The turkey breasts were soft and completely thawed.
During a concurrent interview with Dietary Supervisor (DS) she stated depending on the food item, usually the storage period for meats is three to five days.
During a concurrent review of the facility food storage guidelines and interview with the Dietary supervisor (DS) and Registered Dietitian (RD) at 10:35am, the DS stated the turkey was cooked then frozen and stated the turkey was removed on 8/22/2024 to thaw. The RD stated the turkey was thawed in three days and should be used within two days total of five days. The DS stated the turkey will be discarded for potential growth of microorganism that can cause food borne illness. The DS stated an Inservice will be provided to staff and cooks on the thawing period of food and use by dates.
A review of the facility refrigerated storage guide (dated 2019) indicated for poultry the maximum refrigeration time once meat has thawed is two days.
c. During an observation in the facility walk in freezer on 8/27/2024 at 9:40am, there was one large cardboard box containing 25-30 frozen meals (TV Dinners) stored on the top shelf in the walk-in freezer. The box was not labeled or dated.
During a concurrent observation and interview with the DS, the DS stated the frozen meals belong to one resident. The DS stated residents' family purchases the frozen meals for the resident. The DS stated residents' food should be stored in separate containers that are covered and labeled clearly to be identified and stored separate from the facility food to prevent cross contamination.
The DS stated frozen meals should be in a plastic container with a lid and stored on a shelf separate from the facility food, marked clearly to identify the resident name and date that food was brought in.
During an observation in the facility resident refrigerator located in the employee lounge on 8/28/2024 at 11:50am there were five plastic bags with food stored in the resident refrigerator with no date. One plastic bag with food was delivered on 8/16/24 exceeded the storage period for resident food brought from outside. There were two more bags with food brought in for a resident with no date.
During the same observation in the resident refrigerator there were five nutritional supplements labeled Store frozen with the manufactures instruction to use within 14 days of thawing, which were not monitored for the date they were thawed to ensure expired shakes were discarded at this time frame. There were two chocolates flavored and three strawberry flavored shakes stored in the refrigerator.
During a concurrent observation and interview with Registered Nurse (RN6), RN6 stated food should be labeled clearly with the resident name and the date that it was brought in. RN6 stated food is stored for 72 hours. RN6 sated there are no dates on the bags, and she is not sure when the food was brought in.
During an interview with the DSD on 8/28/2024 at 12:00pm, DSD sated nursing has to date and label the food when it is brought in. DSD stated the food is only stored for 3 days and then it is discarded, DSD stated she doesn't know when the food was brought in since there is no date. DSD stated the bag dated 8/16/24 should have been discarded. DSD stated the food cannot stay longer than 3 days per policy as it will go bad, and resident can get sick.
A review of facility policy titled Food Receiving and Storage (Revised November 2022) indicated, All foods belonging to residents are labeled with the resident's name, the item and the use by date.
A review of facility policy titled Foods Brought by Family/Visitors (Revised March 2022) indicated, Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food .The nursing staff will discard perishable foods on or before the use by date.
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** c. During a review of Resident 135's admission Records (AR), the AR indicated Resident 135 was initially admitted to the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 135's admission Records (AR), the AR indicated Resident 135 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure (a condition when the lungs cannot get enough oxygen into the blood), tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to allow air to reach the lungs) and gastrostomy (an opening into the stomach from the abdominal wall, made surgically, for the introduction of food).
During a review of Resident 135's Minimum Data Set (MDS, a resident assessment and care planning tool) dated 6/6/2024, the MDS indicated Resident 135 had an intact cognition (ability to understand) and totally dependent (helper did all of the effort, resident did none of the effort to complete the activity) with eating, oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 135 had tracheostomy for respiration and feeding tube for nutrition.
During a concurrent observation and interview on 8/27/2024 at 11:48 am with Licensed Vocational Nurse 4 (LVN 4) inside Resident 135's room, Resident 135 was lying in bed on his back with head of bed elevated. Resident 135 had a tracheostomy tube connected to a ventilator (a machine or device used to support or replace breathing) and a gastrostomy tube (a feeding tube to provide nutrition to people who cannot obtain nutrition by mouth, unable to swallow safely, or need nutritional supplementation). LVN 4 stated Resident 135 was not on Enhanced Barrier Precaution, there was no isolation cart outside the room and no signage posted indicating the isolation outside Resident 135's room.
During an interview on 8/27/2024 at 11:55 am with the Infection Preventionist Nurse (IPN- a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment), the IPN stated all residents with colonized MDROs, wounds, and any medical devices like tracheostomy and gastrostomy tube needed to be placed on EBP because they were at high risk for infection. The IPN nurse stated, EBP rooms needed to have an isolation cart for staff and visitors to use and a signage needed to be posted outside the EBP room to remind everyone of the proper precautions to apply.
During an interview on 8/28/2024 at 4:26 pm with the Director of Nursing (DON), the DON stated, residents with medical devices had higher risk of infection and should be placed on EBP, the EBP rooms should be provided with an isolation cart and signage needed to be posted outside the EBP room. The DON stated, gowns and gloves needed to be used for every resident encounter when the resident was placed on EBP.
During a review of the facility's undated Policy and Procedure (P&P) titled, Enhanced Barrier Precautions (EBPs), the P&P indicated, EBPs are utilized to prevent the spread and transmission of multi-drug resistant organisms (MDROs) to residents in long-term care facilities. EBPs are indicated (when contact precautions do not otherwise apply) for residents with unhealed wounds or pressure injuries, who are ventilator-dependent, and those with indwelling medical devices, regardless of their MDRO status or colonization. Signs may be posted on the door or wall outside the resident's room to indicate the appropriate precautions.
d. During a review of Resident 422's admission Record (AR), the AR indicated Resident 422 was admitted to the facility on [DATE], with diagnoses that included respiratory failure, unspecified, unspecified whether with hypoxia (low levels of oxygen) or hypercapnia (excessive carbon dioxide in the blood), Rett's Syndrome (a rare genetic disorder that affects brain development, resulting in severe mental and physical disability), and hyperlipidemia (high levels of fat particles in the blood).
During a review of Resident 422's History and Physical (H&P), dated 8/13/2024, the H&P indicated, Resident 422 did have the capacity to understand and make decisions.
During a review of Resident 422's Minimum Data Set (MDS, a standardized resident assessment care planning tool), dated 8/18/2024, the MDS indicated, Resident 422 had a severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 422 was dependent (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, and personal hygiene. The MDS indicated Resident 422 was dependent for rolling left to right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS indicated Resident 422 had an indwelling catheter (flexible tube that collects urine from the bladder and leads to a drainage bag).
During a review of Resident 422's Care Plan (CP), titled, Foley Catheter/Suprapubic (hollow flexible tube that is used to drain urine from the bladder and is inserted into the bladder through an incision in the abdomen, a few inches below the navel), dated 8/13/2024, the CP indicated Resident 422 was at high risk for UTI (Urinary Tract Infection, an infection in any part of the urinary system) recurrence due to use of an indwelling foley catheter and history of nature of illness/disease process.
During an observation on 8/28/2024 at 11:03 am, Resident 422's Foley catheter tubing was touching the floor.
During a concurrent observation and interview on 8/28/2024 at 11:07 am with Licensed Vocational Nurse 16 (LVN 16), LVN 16 observed Resident 422's Foley catheter tubing touching the floor. LVN 16 stated Resident 422's foley catheter tubing should not be touching the floor because of infection control. LVN 16 stated Resident 422 could develop an infection.
During an interview on 8/29/2024 at 3:06 pm with LVN 3, LVN 3 stated Resident 422's Foley catheter tubing should not be touching the floor because of infection control. LVN 3 stated bacteria can be introduced and migrate to Resident 422.
During an interview on 8/30/2024 at 10:37 am with the infection Preventionist Nurse (IPN), the IPN stated Foley catheter tubing should be below the level of the bladder and in a dignity bag with the tubing hanging on the side of the bed. The IPN stated the Foley catheter tubing should not be touching the floor because it places the resident at risk for infection.
During a review of the facility's Policy & Procedure (P&P), titled, Policies and Practices- Infection Control, revised July 2014, the P&P indicated the facility's infection control policies are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
During a review of the facility's P&P, titled, Catheter Care, Urinary, revised August 2022, the P&P indicated to ensure the catheter tubing and drainage bag are kept off the floor.
Based on observation, interview, and record review, the facility failed to implement infection control practices for seven of 10 sampled residents (Residents 69, 111, 133, 122, 66, 135, and 422) by failing to:
a. Ensure staff wore eye protection, including a face shield or eye goggles, upon entering rooms for Resident 69, 111, 133, and 122 who were under observation for exposure to Coronavirus Disease 2019 (COVID-19, a highly contagious viral disease that can cause respiratory illness) in accordance with the facility's Policy and Procedure (P&P) on Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures.
b. Ensure staff performed hand hygiene and wore a protective gown while adjusting Resident 66's tracheostomy tube (surgical opening made through the front of the neck and into the windpipe [trachea] to allow air into the lungs) in accordance with the facility's P&P on Infection Control Guidelines for All Nursing Procedures.
c. Ensure Resident 135, who had a G-tube and tracheostomy tube, was placed on Enhanced Barrier Precautions (EBP, an infection control practice that uses targeted gown and glove use to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes), provided with isolation cart and signage was posted outside the resident's room in accordance with the facility's P&P on Enhanced Barrier Precautions.
d. Ensure Resident 422's Foley catheter (flexible tube passed through the urethra and into the bladder to drain urine) was not touching the floor.
These failures had the potential to result in the spread of disease and infection and cause illness to the residents.
Findings:
a. During an observation and interview on 8/28/2024 at 9:49 a.m., Residents 111, 133, 122, and 69 were in rooms designated as the Yellow Zone (room designated for exposure to a person with COVID-19). The signs posted prior to entering the residents' rooms in the Yellow Zone indicated to wear a protective gown, wear an N95 respirator (nationally approved face mask that filters at least 95% of airborne particles), wear a face shield or goggles, and wear gloves on room entry. Registered Nurse 4 (RN 4) was observed going into Resident 111 and Resident 133's room without any eye protection, including a face shield or goggles. Housekeeping 1 was observed going into Resident 122 and Resident 69's room without any eye protection. Plastic drawers were located in front of Residents 111, 133, 122, and 69's rooms with protective gowns and boxes of disposable gloves. Restorative Nursing Aide 3 (RNA 3) and RN 4 looked in the plastic drawers but were unable to locate any face shields or goggles.
During an interview on 8/28/2024 at 11:05 a.m. with the Infection Prevention Nurse (IPN- a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment), the IPN stated staff entering rooms in the Yellow Zone should be wearing a face shield, N95 respirator, gown, and gloves since the residents in these room were exposed to COVID-19. The IPN stated the protective equipment was necessary to prevent the spread of COVID-19.
During an interview on 8/28/2024 at 11:57 a.m. with RN 4, RN 4 stated a face shield was not worn in Resident 111 and Resident 133's room because RN 4 was unable to locate any face shields in the plastic drawers of the Yellow Zone.
During a review of the facility's P&P titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised 4/2020, the P&P indicated staff will wear gloves, protective gown, eye protection, and a N95 respiratory for a resident with suspected COVID-19.
b. During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted Resident 66 on 12/19/2023 with diagnoses included cerebral palsy (condition marked by impaired muscle coordination and/or other disabilities), dysphagia (difficulty swallowing), attention to gastrostomy (G-tube, tube placed directly into the stomach for long-term feeding), attention to tracheostomy (surgical opening made through the front of the neck and into the windpipe [trachea] to allow air into the lungs), and dependence on a ventilator (machine that mechanically assists with breathing).
During a concurrent observation and interview on 8/29/2024 at 9:10 a.m. in Resident 66's room, the posted sign prior to entering Resident 66's room indicated Resident 66 was on Enhanced Barrier Precaution. Respiratory Therapist 2 (RT 2) was inside Resident 66's room adjusting Resident 66's tracheostomy tube without wearing a protective gown. RT 2 stated RT 2 was supposed to wear a face mask, gown, and gloves while adjusting Resident 66's tracheostomy tube. RT 2 proceeded to put on a protective gown and gloves but did clean hands prior to putting on the gown and gloves. RT 2 stated she was supposed to clean both hands prior to putting on the protective gown and gloves.
During an interview on 8/30/2024 at 7:50 a.m. with the facility's IPN, the IPN stated EBP were implemented in accordance with local and federal guidelines for any resident with an opening in their body, including but not limited to residents with wounds, tracheostomy tube, and G-tubes. The IPN stated all staff, including the Respiratory Therapists who check residents' tracheostomy tubes, need to follow EBP to decrease the risk of infection to at-risk residents.
During a review of the facility policy and procedure (P&P) titled, Infection Control Guidelines for All Nursing Procedures, revised 8/2012, the P&P indicated employees must wash their hands after handling items potentially contaminated with blood, body fluids, or secretions.
Aug 2024
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall (move dow...
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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 care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 1) who was assessed as high risk for fall by failing to:
1. Ensure Certified Nursing Assistant 1 (CNA 1), the CNA 1 who was assigned to take care of Resident 1, had the knowledge that Resident 1 needed supervision or touching assistance [helper provides verbal cues and/or tactile (touch) cues or contact guard assistance (place one or two hands on the resident's body to help with balance) while the resident completes activity] and provided supervision (the act of overseeing, monitoring or watching over someone) to Resident 1 while Resident 1 was walking in the room and was using the bathroom (toilet use, the act of using a toilet).
2. Ensure Licensed Vocational Nurse 2 (LVN 2) and Registered Nurse 1 were aware of Resident 1's care plans interventions such as encourage Resident 1 to call for assistance, provide assistance as needed, and provide supervision with toilet use, transfer, walking in the room as indicated in Resident 1's Care Plans titled, Activities of Daily Living (ADLs, daily tasks that people perform to care for themselves and maintain independence) and Fall Risk.
As a result, on 8/3/2024, at around 9 AM, Resident 1 fell in the bathroom. Resident 1 experienced pain (unrated) on the left shoulder and was transferred to General Acute Care Hospital 1 (GACH 1) via Emergency Transportation (ambulance services) for further evaluation. At GACH 1 Resident 1 was found to have a left humeral (upper arm bone) neck impacted fracture (occurs when the broken ends of the bone are jammed together by force of the injury) and the greater tuberosity (bony bump at top of humerus) had mildly displaced fracture fragment (occurs when a broken bone moves enough to create a gap around the fracture, and the pieces of the bone are no longer aligned).
Cross Reference F656
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/27/2021 and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM2- elevated blood sugar level) with diabetic chronic kidney disease (damage to the kidneys so they cannot filter blood properly), dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time).
During a review of Resident 1's Fall Risk Assessment (FRA) dated 11/27/2023, the FRA indicated Resident 1 was assessed as high risk for falls due to intermittent (occurring at irregular intervals; not continuous or steady) confusion, currently taking three - four medications (unspecified) and had one - two predisposing disease condition (unspecified).
During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 5/21/2024, the MDS indicated Resident 1 had moderately impaired cognition (ability to think and process information). The MDS indicated Resident 1 required supervision or touching assistance for toilet transfer (ability to get on and off a toilet or commode) and walking at least 10 feet in a room, corridor (a long passage in a building from which doors lead into rooms), or similar space.
During a review of Resident 1's Care Plan (CP) titled, Fall Risk, dated 5/21/2024, the CP indicated Resident 1 was at risk for fall related to depression (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities) secondary to dementia, use of anti-depressants (medication to treat depression) and poor safety awareness. The CP interventions included for staff (in general) to encourage Resident 1 to call for assistance as needed, assist Resident 1's ADL as needed, and conduct frequent visual checks of Resident 1.
During a review of Resident 1's CP titled, ADL, dated 5/21/2024, the CP indicated Resident 1 had ADL deficit related to dementia and depression. The CP indicated Resident 1 required supervision with toilet use, transfer, walking in the room and walking in the corridor. The CP interventions included for staff to assist Resident 1 with ADL as needed and to monitor Resident 1 for ADL needs.
During a review of Resident 1's History and Physical Examination (H&P) dated 8/1/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions due to dementia.
During a review of Resident 1's Situation-Background-Assessment-Recommendation Summary for Providers (SBAR- communication tool about a resident's condition), dated 8/3/2024 and timed at 9:30 AM, the SBAR indicated on 8/3/2024 (untimed) the Charge Nurse/Registered Nurse 1 (RN 1) was alerted by a scream and found Resident 1 lying on the floor. Resident 1 complained of left shoulder pain (unrated). The SBAR indicated Resident 1 refused to get up due to shoulder pain (unrated). The SBAR indicated Resident 1 did not use the call light for assistance. The SBAR indicated Resident 1's Primary Care Provider/Medical Doctor 1 (MD 1) recommended sending Resident 1 to GACH 1. The SBAR indicated Resident 1 was transferred to GACH 1 on 8/3/2024 at 9:30 AM via emergency services.
During a review of Resident 1's MD 1's physician order dated 8/3/2024, the MD 1's physician order indicated to send Resident 1 to GACH 1 for status post (after) fall on 8/3/2024.
During a review of Resident 1's GACH 1 Radiology (X-ray a photographic or digital image of tissues and structures inside the body) Report of the left humerus dated 8/3/2024 at 10:08 AM, the X-ray report indicated Resident 1 sustained a left humeral neck impacted fracture, the greater tuberosity had mildly displaced fracture fragment, and there was diffused osteopenia (a condition in which there is a lower-than-normal bone mass or bone mineral density).
During an interview on 8/7/2024 at 1:30 PM with RN 1(assigned RN for Resident 1), RN 1 stated Resident 1 had an unwitnessed fall on 8/3/2024 at around 9 AM. RN 1 stated RN 1 found Resident 1 on the bathroom floor after Resident 1 walked to the bathroom unsupervised. RN 1 stated, Resident 1 could walk independently and did not need supervision with walking. RN 1 stated Resident 1 only needed redirection at times due to confusion from dementia.
During a concurrent observation of Resident 1 in Resident 1's room and interview with Resident 1 on 8/7/2024 at 3:37 PM, Resident 1 was awake, lying in bed, using a blue arm sling (a device that supports and keeps an injured arm still, or immobilizes it) on the left arm. Upon interview, Resident 1 stated her left arm was injured from playing football with doctors. Resident 1 stated she had no concerns. Resident 1 did not answer additional questions.
During an interview on 8/7/2024 at 3:49 PM with LVN 2, LVN 2 stated LVN 2 took care of Resident 1 before the fall on 8/3/2024. LVN 2 stated Resident 1 would ambulate to the bathroom independently without the need for supervision. LVN 2 stated LVN 2 was unaware Resident 1 required supervision during ADL.
During a concurrent interview and record review on 8/9/2024 at 9:54 AM with MDS Nurse 1 (MDS 1), Resident 1's MDS dated [DATE] was reviewed. The MDS under Section GG (Functional Abilities and Goals - a section of the MDS which assesses a resident's functional abilities and goals by indicating assistance level needed to complete an activity) indicated Resident 1 needed supervision or touching assistance for ambulation and supervision for toileting transfer. MDS 1 stated, based on the MDS (dated 5/21/2024), Resident 1 required a staff member (any staff member) to be present when Resident 1 walked or used the bathroom/restroom for safety. MDS 1 stated Resident 1's fall could have been prevented if staff supervision was provided (on 8/3/2024).
During an interview on 8/9/2024 at 10:46 AM with MDS Nurse 2 (MDS 2), MDS 2 stated, MDS 2 completed Resident 1's MDS dated [DATE]. MDS 2 stated when Resident 1 walked to the restroom, a staff member (any staff member) needed to be present to watch and supervise Resident 1. MDS 2 stated, supervision meant a staff member needed to be with Resident 1 and provided constant visual checks.
During an interview on 8/9/2024 at 1:16 PM with CNA 1, CNA 1 stated she was the assigned CNA for Resident 1 during the fall on 8/3/2024. CNA 1 stated Resident 1 did not require assistance or supervision to walk to the bathroom/restroom or inside the room. CNA 1 stated when Resident 1 fell, CNA 1 was in the dining room monitoring other residents.
During an interview on 8/9/2024 at 2:27 PM with the Lead Licensed Vocational Nurse (Lead LVN), the Lead LVN stated Resident 1 was not always alert and would be confused at times. Lead LVN stated Resident 1 needed supervision in the room and bathroom. Lead LVN stated when Resident 1's MDS assessments and care plans interventions (provide supervisions) for fall prevention and ADLs were not followed, it resulted in serious harm and injury to Resident 1.
During a review of the facility's Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, revised 12/2007, the P&P indicated, based on previous evaluations and current data, the staff identified interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
During a review of the facility's P&P titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated, resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The P&P indicated, the care team targeted interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated, implementing interventions to reduce accident risks and hazards included communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, and ensuring that interventions were implemented. The P&P indicated, resident supervision was a core component of the systems approach to safety. The type and frequency of supervision may vary among residents and over time for the same residents.
During a review of the facility's P&P titled, Care Plans - Comprehensive, revised 9/2010, the P&P indicated for policy implementation, the facility develops and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.
During a review of the facility's P&P titled, Activities of Daily Living (ADL) Supporting, revised 3/2018, the P&P indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking) and elimination (toileting). The P&P indicated, a resident's ability to perform ADLs will be measured using clinical tools, including the MDS.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for ADL (Activi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for ADL (Activities of Daily Living, daily tasks that people perform to care for themselves and maintain independence) and Fall Risk for one of one sampled resident (Resident 1), who was assessed as high risk for falls ( to move downward, typically rapidly and freely without control, from a higher to a lower level).
This deficient practiced placed Resident 1 at risk for falls.
As a result, on 8/3/2024, Resident 1 fell in the bathroom. Resident 1 experienced pain (unrated) on the left shoulder and was transferred to General Acute Care Hospital 1 (GACH 1) via 911 (an emergency telephone number) for further evaluation. At GACH 1 Resident 1 was found to have a left humeral (upper arm bone) neck impacted fracture (occurs when the broken ends of the bone are jammed together by force of the injury) and the greater tuberosity (bony bump at top of humerus) mildly displaced fracture fragment (occurs when a broken bone moves enough to create a gap around the fracture, and the pieces of the bone are no longer aligned).
Cross Reference F689
Findings:
During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/27/2021 and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM2- elevated blood sugar level) with diabetic chronic kidney disease (damage to the kidneys so they cannot filter blood properly), dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time).
During a review of Resident 1 ' s Fall Risk Assessment (FRA) dated 11/27/2023, the FRA indicated Resident 1 was assessed as high risk for falls due to intermittent (occurring at irregular intervals; not continuous or steady) confusion, currently taking three - four medications (unspecified) and had one - two predisposing disease condition (unspecified).
During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 5/21/2024, the MDS indicated Resident 1 had moderately impaired cognition (ability to think and process information). The MDS indicated Resident 1 required supervision or touching assistance for toilet transfer (ability to get on and off a toilet or commode) and walking at least 10 feet in a room, corridor (a long passage in a building from which doors lead into rooms), or similar space.
During a review of Resident 1's Care Plan (CP) titled, Fall Risk, dated 5/21/2024, the CP indicated Resident 1 was at risk for fall related to depression (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities) secondary to dementia, use of anti-depressants (medication to treat depression) and poor safety awareness. The CP interventions included for staff (in general) to encourage Resident 1 to call for assistance as needed, assist Resident 1 ' s ADL as needed, and conduct frequent visual checks of Resident 1.
During a review of Resident 1's CP titled, ADL, dated 5/21/2024, the CP indicated Resident 1 had ADL deficit related to dementia and depression. The CP indicated Resident 1 required supervision with toilet use, transfer, walking in the room and walking in the corridor. The CP interventions included for staff to assist Resident 1 with ADL as needed and to monitor Resident 1 for ADL needs.
During a review of Resident 1 ' s Situation-Background-Assessment-Recommendation Summary for Providers (SBAR- communication tool about a resident ' s condition), dated 8/3/2024 and timed at 9:30 AM, the SBAR indicated on 8/3/2024 (untimed) the Charge Nurse/Registered Nurse 1 (RN 1) was alerted by a scream and found Resident 1 lying on the floor. Resident 1 complained of left shoulder pain (unrated). The SBAR indicated Resident 1 refused to get up due to shoulder pain (unrated). The SBAR indicated Resident 1 did not use the call light for assistance. The SBAR indicated Resident 1 ' s Primary Care Provider/Medical Doctor 1 (MD 1) recommended sending Resident 1 to GACH 1. The SBAR indicated Resident 1 was transferred to GACH 1 on 8/3/2024 at 9:30 AM via emergency services.
During an interview on 8/7/2024 at 3:49 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated before the fall on 8/3/2024 Resident 1 would ambulate to the bathroom independently without need for supervision. LVN 2 stated, Resident 1 was forgetful and needed redirection and did not require supervision during ADLs prior to the fall. LVN 2 further stated, LVN 2 was unaware of Resident 1 ' s care planned interventions for Fall and ADLs.
During an interview on 8/9/2024 at 10:46 AM with MDS Nurse (MDS 2), MDS 2 stated, MDS 2 completed Resident 1 ' s MDS dated [DATE]. MDS 2 stated when Resident 1 walked to the restroom, a staff member (any staff member) needed to be present to watch and supervise Resident 1. MDS 2 stated, supervision meant a staff member needed to be with Resident 1 and provided constant visual checks.
During an interview on 8/9/2024 at 11:48 AM with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated he previously took care of Resident 1 and Resident 1 was occasionally confused and had dementia. CNA 3 stated, he was unaware of Resident 1 ' s care planned interventions for falls and was not aware Resident 1 needed supervision when walking or when using the bathroom as indicated in the resident ' s care plan.
During an interview on 8/9/2024 at 1:16 PM with CNA 1, CNA 1 stated she was the assigned CNA for Resident 1 during the fall on 8/3/2024. CNA 1 stated Resident 1 did not require assistance or supervision to walk to the bathroom/restroom or inside the room. CNA 1 stated when Resident 1 fell, CNA 1 was in the dining room monitoring other residents. CNA 1 was unaware about Resident 1 ' s care planned intervention that required supervision when walking.
During an interview on 8/9/2024 at 2:27 PM with the Lead Licensed Vocational Nurse (Lead LVN), the Lead LVN stated Resident 1 was not always alert and would be confused at times. Lead LVN stated the resident ' s care plans provide interventions to take care of the residents. Lead LVN stated, Resident 1 needed supervision in the room and bathroom. Lead LVN further stated, when Resident 1 ' s care plans for fall prevention and ADLs were not followed, it resulted in serious harm or injury to Resident 1.
During a review of the facility ' s Policy and procedure (P&P) titled, Care Plans – Comprehensive, revised 9/2010, the P&P indicated for policy implementation, the facility develops and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure infection prevention and control practices were implemented ...
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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 infection prevention and control practices were implemented for one of two sampled residents (Resident 6) and a census of 205 residents as indicated in the facility's policy and procedure (P&P) titled Policies and Practices- Infection Control, and the Los Angeles County Department of Public Health guidelines titled, Scabies Prevention and Control Guidelines for Healthcare Settings, by failing to:
1. Ensure Resident 6 did not experience a delay in treatment when Resident 6 tested positive for Scabies (a highly contagious skin condition caused by tiny insects called mites that infest and causes intense itching) on 7/31/2024.
2. Ensure the Infection Preventionist (IP; healthcare professional that is trained to develop ways to detect, prevent, and control the spread of disease in healthcare settings) reported the facility's Scabies Outbreak (two or more clinically suspect or confirmed cases of scabies identified in residents, healthcare workers, volunteers and/or visitor during a six (6) week period) to the Los Angeles County Department of Public Health and California Department of Public Health (CDPH).
These deficient practices had the potential to spread Scabies to other residents, visitors, and staff members in the facility.
Findings:
1. During a review of Resident 6's admission Record (AR), the AR indicated, the facility readmitted Resident 6 to the facility on 7/1/2024, with diagnoses that included encephalopathy, unspecified, (a range of conditions that alters brain function or structure), end stage kidney disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and dysphagia (difficulty swallowing) oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat).
During a review of Resident 6's History and Physical Examination (H&P), dated 7/3/2024, the H&P indicated, Resident 6 did not have the capacity to understand and make decisions.
During a review of Resident 6's Body Assessment (BA), dated 7/31/2024, the BA indicated, Resident 6's chest and right thigh had worsening rash with red raised bumps. The BA indicated, Resident 6 was started on Doxycycline (medication used to treat and prevent infection).
During a review of Resident 6's Nurses Progress Notes (NPN), dated 7/31/2024, timed at 9:56 AM, the NPN indicated, (on 7/31/2024, untimed), Resident 6 was seen and examined by Physician 1 for generalized rashes with recommendation for skin scraping (procedure to get a small sample of skin for examination under a microscope to look for mites and mite eggs) to be done that same day to rule out Scabies. The NPN indicated, physician's order (PO) was noted and carried out.
During a review of Resident 6's Scabies Exam Laboratory (facility with equipment for doing scientific tests) Result (Scabies Exam Lab Result) dated 7/31/2024, timed at 10:39 PM, the Scabies Exam Lab Result indicated, the skin scraping collected on 7/31/2024 and timed at 12 AM, tested positive for sarcoptes scabiei (itch mite that is a parasitic arthropod that burrows into skin and causes scabies) adults and egg.
During a review of Resident 6's Scabies Exam Lab Result, dated 7/31/2024, the Scabies Exam Lab Result indicated, a note that the laboratory attempted to provide the facility with Resident 6's lab results on 7/31/2024 at 11:04 PM and 11:11 PM, but there was no answer.
During a review of Resident 6's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 8/3/2024, the MDS indicated, Resident 6 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated, Resident 6 was dependent (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) for oral hygiene, toileting hygiene, showering/bathing self, and personal hygiene. The MDS indicated, Resident 6 was dependent for rolling left and right in bed (the ability to roll from lying on back to left and right side and return to lying on back on the bed).
During a review of Resident 6's NPN, dated 8/7/2024, timed at 11:14 AM, the NPN indicated, the treatment nurse received positive SE Lab Results for Resident 6 and informed the IP. The NPN indicated, Resident 6 was placed on contact isolation (precautions intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment) and proper protocol for Scabies was initiated.
During a review of Resident 6's NPN, dated 8/7/2024, timed at 12:43 PM, the NPN indicated, during morning rounds with Physician 1, Resident 6's positive skin scraping results for scabies were received. The NPN indicated, Physician 1 ordered Ivermectin (medication that treats parasitic [relating to a parasite, an organism that lives on or in a host organism and gets its food from or at the expense of its host] diseases) and Permethrin (Elimite, medication used to treat scabies) for Resident 6. The NPN indicated, the PO were noted and carried out.
2. During a review of Resident 8's AR, the AR indicated, the facility readmitted Resident 8 to the facility on 6/10/2024, with diagnoses that included anoxic brain damage (a complete lack of oxygen to the brain which results in permanent brain damage), not elsewhere classified, anemia (a low number of red blood cells), and dysphagia, oropharyngeal phase.
During a review of Resident 8's History and Physical Examination (H&P), dated 5/9/2024, the H&P indicated, Resident 8 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 severe impairment in cognitive skills for daily decision making.
During a review of Resident 8's BA, dated 6/10/2024, the BA indicated, Resident 8 had generalized rashes to Resident 8's chest.
During a review of Resident 8's Scabies Exam Lab Result, dated 7/4/2024, timed at 1:03 AM, the Scabies Exam Lab Result indicated, the skin scraping collected on 7/3/2024 and timed at 9:35 PM, tested positive for sarcoptes scabiei adults and egg.
During an interview on 8/8/2024 at 2:05 PM with the IP, the IP stated Resident 6 was treated with Elimite (on 8/8/2024). The IP stated Resident 6 was treated with Ivermectin the previous day (8/7/2024). The IP stated Resident 8's skin scraping also tested positive for Scabies four weeks ago (7/3/2024).
During an interview on 8/8/2024 at 2:25 PM with the IP, the IP stated the IP did not report the positive cases of Scabies because it was not considered an outbreak.
During a concurrent interview and record review on 8/8/2024 at 5:04 PM with the IP, the IP stated they received Resident 6's positive Scabies result yesterday (8/7/2024) which was verified by skin scraping. The IP stated Resident 6's skin scraping was done on 7/31/2024 at 12 AM. The IP stated the resulted date was 7/31/2024 at 10 PM. The IP stated he was made aware of the positive results yesterday (8/7/2024). The IP stated the IP and facility staff did not know Resident 6's skin scraping results were available (before 8/7/2024). The IP stated the IP was not made aware a skin scraping was done for Resident 6 on 7/31/2024. The IP stated the treatment nurses completed the skin scraping. The IP stated according to what the IP was reading and what the facility's consultant stated, the definition of a Scabies outbreak was two or more positive cases or one or more suspected case within a two-week period. The IP stated he did not inform the Department of Public Health about the positive cases of Scabies. The IP stated he did not know it was considered an outbreak. The IP stated he considered the facility's positive cases of Scabies as an outbreak according to the Los Angeles Acute Communicable Disease Control (ACDC, local public health agency responsible for preventing and controlling infectious disease in Los Angeles County) guidelines. The IP stated the IP did not make a mistake but was not updated regarding the current guidelines.
During an interview on 8/9/2024 at 11:11 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 6 had an ongoing rash and Physician 1 ordered a skin scraping on 7/31/2024. LVN 3 stated there was a delay with the lab result and the facility staff did not follow up on the lab result. LVN 3 stated charge nurses, wound care nurses, and LVNs were responsible for checking and follow-up on residents' lab results. LVN 3 stated she followed up on Resident 6's Scabies Exam Lab Result on 8/7/2024. LVN 3 stated the risk of not following up timely on Resident 6's Scabies Exam Lab Result could result in transfer/transmission of Scabies to other residents.
During a telephone interview with Physician 1 on 8/9/2024 at 12:47 PM with Physician 1, Physician 1 stated there was a delay in starting Scabies treatment for Resident 6. Physician 1 stated if there was a delay in starting treatment for Scabies, and if the staff was not using isolation gowns, staff could be in contact (with the mites) and could spread Scabies.
During a review of the facility's P&P titled, Policies and Practices- Infection Control, revised July 4014, the P&P indicated, the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The P&P indicated, the objectives of the facility's infection control policies and practices were to prevent, detect, investigate, and control infections in the facility and maintain records of incidents and corrective actions related to infections.
During a review of the Los Angeles County Department of Public Health Acute Communicable Disease Control Program guidelines (LAC DPH ACDC guidelines), titled, Scabies Prevention and Control Guidelines for Healthcare Settings, dated July 2019, the LAC DPH ACDC guidelines indicated, the definition of outbreak was two (2) or more clinically suspect or confirmed cases of scabies identified in patients/residents, healthcare workers, volunteers and/or visitors during a six (6) week time period. The LAC DPH ACDC guidelines indicated, all outbreaks of scabies were required to be reported to the LAC Department of Public Health and California Department of Public Health (Licensing and Certification).
During a review of the facility's undated, Charge Nurse- RN/LVN, job description, indicated to report results of labs, x-rays, etc. to physician, documenting call, response, and new orders as appropriate.
Jul 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
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 copies of medical records upon request within two working d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide copies of medical records upon request within two working days for two of three sampled residents (Resident 7 and Resident 8).
This deficient practice had the potential to violate Resident 7's, Resident 8's, and/or their representative's right to obtain copies of their medical records in a timely manner.
Findings:
1. During a review of Resident 7's Face Sheet (FS- admission Record), the FS indicated, the facility admitted Resident 7 on 8/31/21, with diagnoses that included Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks,) epilepsy (brain disorder in which a person has repeated seizures [episodes of disturbed brain activity that cause changes in attention or behavior] over time). The FS indicated, Resident 7's responsible party (RP) was RP 1.
During a review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/2/24, the MDS indicated, the facility was unable to test Resident 7's cognition. The MDS indicated, Resident 7 was dependent on staff for all activities of daily living.
During a review of the facility's document titled Disclosure Log, from 3/1/24 to 6/11/24, the log indicated, Resident 7's responsible party (RP 1) requested Resident 7's medical records on 5/30/24, untimed.
During a review of the e-mail communication between the facility and RP 1 dated 6/12/24, timed at 10:52 am, the e-mail communication indicated, the facility notified RP 1 that copies of Resident 7's medical records were ready to be picked up.
During an interview on 7/23/24 at 10:15 am with the Medical Records Staff (MRS) 1, MRS 1 stated the Medical Records Department's goal would be to release medical records requested immediately upon request with a maximum of 72 hours upon request.
During an interview on 7/23/24 at 11:00 am with MRS 1, MRS 1 stated all requests would be sent to corporate (relating to large companies) staff for review and processing. MRS 1 stated as soon as the Medical Records Department received a request for medical records, MRS 1 would make copies of the records right away, scan, then e-mail the records to corporate staff for review. MRS 1 stated the consultants from corporate office would be the one to make the determination when to release the medical records to the requester.
2. During a review of Resident 8's FS, the FS indicated, the facility admitted Resident 8 on 3/7/24, with diagnoses that included hemiplegia (one sided weakness) following a cerebral infarction (stroke - sudden death of brain cells in a localized area due to inadequate blood flow) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). The FS indicated, Resident 8's responsible party was RP 2.
During a review of Resident 8's MDS dated [DATE], the MDS indicated, the facility was unable to assess Resident 8's cognition. The MDS indicated, Resident 8 required moderate assistance with all activities of daily living.
During a review of the document titled Disclosure Log, from 3/1/24 to 6/11/24, the log indicated, Resident 8's responsible party requested medical records on 5/29/24, untimed.
During an interview on 7/23/24 at 11:00 am with MRS 1, MRS 1 stated Resident 8's medical records were still being reviewed by the facility's consultants. MRS 1 stated she was still waiting for communication from the facility's consultants and for the facility's consultants to agree to release Resident 8's medical records to the requester.
During an interview on 7/23/24 at 2:25 pm with the Medical Records Director (MRD), the MRD stated Resident 8's medical records were still being reviewed before the records would be released.
During a review of the facility's policy and procedure (P&P) titled, Release of Information, dated November 2009, the P&P indicated, the resident may initiate a request to release information contained in his/her records to anyone he/she wishes. Such requests were honored only upon the receipt of a written, signed, and dated request from the resident or representative. The P&P indicated, a resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident's written or oral request. The P&P indicated, a resident may obtain photocopies of his or her records by providing the facility with at least a (48) hour (excluding weekends and holidays) advance notice of such request.
Jul 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a scabies (skin infestation caused by the human itch mite; ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a scabies (skin infestation caused by the human itch mite; a parasite that lives on the exterior of its host) line list (a table that contains key information about each case in an outbreak) of all residents, staff, visitors, and family members who may have had direct and physical contact with Resident 1 after General Acute Care Hospital (GACH) 1 reported to the facility on 7/8/24, that Resident 1 had a positive scabies result.
This failure had the potential outcome to spread scabies to 51 residents in the Subacute Unit of the facility.
Findings:
1. During a review of Resident 1's admission Record (AR), the AR indicated, the facility initially admitted Resident 1 to the facility on [DATE], and readmitted Resident 1 on 2/13/24, with diagnoses that included respiratory failure, unspecified with hypoxia (occurs when you do not have enough oxygen in your blood) or hypercapnia (occurs when there is too much carbon dioxide in your blood); tracheostomy (a surgical opening into the windpipe to allow air to fill the lungs, with a tube through it to provide an airway and to remove secretions from the lungs); gastrotomy (a surgical opening through the abdomen to the stomach where a feeding device is put into this opening so that feed can be delivered directly into the stomach, bypassing the mouth and throat); dysphagia (difficulty swallowing) oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat); and dependence of respirator [ventilator] status (unable to wean off a ventilator and breathe independently).
During a review of Resident 1's Departmental Note (DN), dated 6/24/24 at 10:21 a.m., the DN indicated, New order to continue with current tx [treatment] apply Lotrisone/Clindamycin lotion (medicated lotion used to treat acne [pimples]) to generalize body BID [two times/per day] x 21 days (Rash Dermatitis- an area of irritated or swollen skin).
During a review of Resident 1's DN, dated 6/25/24 at 11:42 a.m., the DN indicated, Resident 1 with patchy redness on patient tummy extending to upper chest. The DN indicated, the licensed nurse made Medical Doctor (MD) 1 aware and MD 1 ordered Diphenhydramine (medication used to relieve symptoms of allergy, hay fever (your immune system attacks a harmless substance that you come across in the environment) 25mg via gastrostomy tube (GT- tube inserted through the abdomen that brings nutrition and medication directly to the stomach) every (Q) six (6) hours as needed (PRN) for itching. The DN indicated, MD 2 was rounding that week and could assess Resident 1in person.
During a review of Resident 1's change in condition note titled, Renew SBAR (Situation-Background-Assessment-Recommendation), dated 6/25/24 at 4:39 p.m., the SBAR note indicated, 11:35 am It was noted patchy redness on patient tummy extending to upper chest. Pt is awake, alert, and oriented x 4, able to make needs known. RN supervisor spoke with MD 1 made aware, with order to give Diphenhydramine 25mg via GT (gastrostomy tube, a tube inserted through the belly that brings nutrition directly to the stomach) Q 6 hours PRN (as needed) for itching. Per MD 1, MD 2 is rounding this week and can assess it in person when rounds.
During a review of Resident 1's Internist Progress Note (IPN), dated 6/25/24, the IPN indicated, Subjective: rash of breast still itches, adding creams. Assessment: Recurrent right breast infection. Plan: Continue care in Subacute rehab; continue to monitor right breast site for erythema. The IPN indicated no documented assessment for Resident 1's patchy redness on the tummy extending to upper chest and no new physician orders.
During a review of Resident 1's DN, dated 7/7/2024 at 10:18 p.m., the DN indicated, MD 3 ordered to transfer Resident 1 to GACH 1 for evaluation due to GT site surrounding redness and infection.
2. During a review of Resident 2's AR, the AR indicated, the facility initially admitted Resident 2 to the facility on [DATE], and readmitted Resident 2 on 5/6/24, with diagnoses that included respiratory failure, volvulus (an obstruction due to twisting or knotting of the gastrointestinal tract), persistent vegetative state (a chronic state of brain dysfunction in which a person shows no signs of awareness), and dysphagia following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and metabolic encephalopathy (chemical imbalance in the blood caused by illness or organs that are not working as well as they should).
During a review of the facility's Physician Orders, dated June 2024, for the following Sub-Acute resident, the PO indicated the following,
For Resident 5,
1. Permethrin 5% Cream - Apply from neck to toe topically at bedtime. Give shower after 12 hours q week on Thursday x 3 doses (On at 9PM, OFF at 9AM) for Scabies ***first dose 5/22/24 in the hospital.
2. Clotrimazole/Betamethasone 1%/0.5% CR to affective areas BID x 21 days (Dx Dermatitis)
Order Date: 5/26/24; Start Date: 5/26/24; Discontinue Date: 6/15/24.
During a review of the facility's Physician Orders (PO), dated July 2024 for the following Subacute Unit residents, the PO indicated the following:
For Resident 3,
Permethrin (medication used to treat scabies and lice) 5% topical cream - Apply topically 9PM, Every 7 days for 2 doses. Leave for 8-10 HRS then shower. Order Date: 7/11/24; Start Date: 7/12/24; Stop Date: 7/19/24.
For Resident 4,
Permethrin 5% topical cream - Apply topically 9PM, Every 7 days for 2 doses. Leave for 8-10 HRS then shower for Dermatitis. Order Date: 7/11/24; Start Date: 7/12/24; Stop Date: 7/29/24.
For Resident 5,
1. Apply Clotrimazole/Betamethasone (a medication used in the management and treatment of fungal infections) Cream 1% to upper trunk BID x 21 days (Dermatitis). Start Date: 6/29/24; Stop Date: 7/28/24.
2. Hydrocortisone 1% cream - Apply to affected areas Q8H PRN/itchiness. Order Date: 4/10/24; Start date: 4/11/24.
3. Hydroxyzine HCl 25 mg tablet - Give 1 tab - 25 mg via GT every 12 hours PRN for itching. Order Date: 4/11/24; Start Date: 4/11/24.
4. Dermatology consult for unresolved rashes. Order Date: 3/1/24; Start Date: 3/1/24.
During an interview on 7/11/24 at 2:25 p.m. with the Infection Preventionist (IP- a trained professional who helps develop ways to detect, prevent, and control the spread of disease in healthcare settings which helps keep patients and staff safe), the IP stated, There is no scabies currently in the facility. The IP stated, There is a SNF (skilled nursing facility) side and a subacute side and both sides have C. auris (Candida auris, a fungus that causes severe, often multidrug-resistant, infections and can be spread in healthcare settings through contact with contaminated surfaces or equipment, or from physical contact with a person who is infected or colonized) residents.
During a concurrent interview and record review on 7/11/24 at 4:20 p.m. with the Director of Staff Development (DSD), the facility's recent in-services titled, Infection Control: Scabies, Donning/Doffing, Proper PPE, Hand Hygiene, Foley Catheter Care, Skin Assessment, dated 7/3/24 and 7/5/24, were reviewed. The DSD stated when events or incidents occur in the facility, she would do an in-service for the staff. The DSD stated she recently did in-services for infection control at the request of the IP.
During an interview on 7/12/24 at 8:13 a.m. with the Treatment Nurse (TN), the TN stated he did not treat any residents for scabies.
During an interview on 7/12/24 at 3:40 p.m. with Licensed Vocational Nurse (LVD) 4, LVN 4 stated, the wound doctor was ongoingly treating Resident 1's rashes. LVN 4 stated Resident 1 looked dry when she left the facility a couple of week ago. LVN 4 stated Resident 1 would scratch and was itchy. LVN 4 stated per Resident 1, the Atarax (medication used to treat anxiety, nausea, vomiting, allergies, skin rash, hives, and itching) helped Resident 1. LVN 4 stated s staff were applying lotion and A&D ointment (protective barrier to help protect cracked skin and helps soothe dry skin) to Resident 1's trunk area. LVN 4 stated Resident 1's skin was read from scratching it but had no fluid discharge. LVN 4 stated GACH 1 called the facility and the IP infection control said Resident 1 had scabies. LVN 4 stated LVN 4 was not offered Elimite (an anti-parasite medication used to treat head lice and scabies). LVN 4 stated LVN 4 did not have any rash or itching. LVN 4 stated Resident 1 was scratching Resident 1's upper chest and trunk area. LVN 4 stated Resident 2 had dryness on the skin, and it was a chronic problem.
During a concurrent interview and record review on 7/12/24 at 4:49 p.m. with Medical Records Director (MRD), Resident 2's DN, dated 7/11/24 at 6:07 p.m., was reviewed. The DN indicated a late entry for 7/8/24 (untimed) was documented. The DN indicated, the IP endorsed to 3 pm to 11 pm registered nurse to notify MD of resident's possible exposure to scabies due to positive results of scabies at GACH 1 from resident's roommate [Resident 1] and see if doctor would want treatment prophylaxis (PPX- an attempt to prevent disease) for resident based on resident's skin condition after assessment. The DN indicated, the RN would notify MD and family as needed. The DN indicated, Resident 2 was by herself in room with Enhanced Standard Precautions (ESP- a comprehensive strategy to prevent, contain, and mitigate infections in skilled nursing facilities and other healthcare settings] due to current multidrug-resistant organisms (MDROs- bacteria that are resistant to one or more classes of antimicrobial agent). The DN indicated, Resident 2 would remain on ESP at this time.
During a concurrent interview and record review on 7/12/24 at 4:10 p.m. with the Director of Nursing (DON), Resident 2's Short Term Problems Care Plan (ST CP), dated 7/8/24 was reviewed. The ST CP indicated, Resident 2 was exposed to roommate with positive scabies (Resident 1. The ST CP approaches indicated, Resident 2 was in the room by herself, for staff to monitor Resident 2 for rashes and notify the MD, and to administer Elimite 5% Topical Cream as ordered.
During a concurrent interview and record review on 7/15/24 at 8:50 a.m. with the IP, Resident 2's DN, dated 7/11/24, timed at 6:07 p.m., was reviewed. The IP acknowledged the IP made a late entry on Resident 2's DN on 7/11/24 at 6:07 p.m. for 7/8/24 date. The IP stated GACH 1 called the IP on 7/8/24 and reported that Resident 1 tested positive for scabies at GACH 1. The IP stated the IP endorsed to the 3 p.m. to 11 p.m. RN to notify Resident 2's physician regarding Resident 2's exposure to scabies. The IP stated there was no skin scraping done/ordered for Resident 2. The IP stated MD 2 ordered Elimite 5% topical cream as a prophylaxis for Resident 2. The IP stated Resident 1 resided at the facility, then was transferred to GACH 1 due to concern for G-tube infection. The IP stated, Resident 1 did not test positive here (at the facility), so no line list is required for tracking residents or staff. The IP acknowledged the IP did not have a line list for any subacute residents, staff or family that may have had direct contact with Resident 1 or Resident 2. The IP stated the facility did not have a dermatologist for at least 6 months and the new DON was looking into obtaining a dermatologist for the facility.
During an interview with the IP on 7/15/24 at 12:12 p.m. with the IP stated when Elimite was ordered on 7/8/24 at 5:00 p.m., Resident 2 did not receive treatment until 7/9/24 at 2:00 a.m. The IP stated due to after-hours pharmacy delivery, medications could take up to 4 to6 hours to be received by the facility as the pharmacy courier goes to different facilities. The IP stated for scabies, there should be contact isolation (intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment) for 24 hours after a resident received treatment. The IP stated staff must observed contact isolation before entering the room (must wear personal protective equipment [PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries or illnesses]) and must remove PPE before exiting the room).
During a concurrent interview and record review on 7/15/24 at 12:27 p.m. with the DSD, the facility's Scabies (Revised January 2012) and Skin Assessment (October 2019) policies were reviewed. The DSD stated infection control issues were handled by the IP. The DSD stated, any resident skin issues like rashes noticed during shower duties or ADLs must be reported by the certified nursing assistant (CNA)to the charge nurse to reassess. The DSD stated skin issues were also reported to the treatment nurse by CNAs and the treatment nurse and charge nurse would reassess the resident. The DSD stated the facility did not have a Dermatologist on staff, but she will check on status with the DON. The DSD stated, One case mentioned by IP for scabies, but not sure if it was recent. The DSD stated, Two or more cases are reportable to Public Health. The DSD stated CNAs were informed to look out for signs and symptoms related to infection like fever or anything new and not on the resident's baseline then report to the charge nurse.
During an interview on 7/15/24 at 2:46 p.m. with the DSD stated, A line list should be created for Resident 2, who was exposed to Resident 1. The DSD also stated, The importance of the line list is to determine who may have been exposed to scabies. The staff should be included in the line list and family members should be notified about possible exposure to scabies. The treatment nurse notes will indicate what actions were taken and who was notified about the exposure to scabies.
During a telephone interview on 7/16/24 at 3:45 p.m. with the IP, the IP stated the IP was not aware that he needed to create a line list for Resident 1 who was discharged on 7/7/24 to GACH 1. The IP stated he did not need to create a line list for Scabies outbreak because Resident 1 tested positive at GACH 1 and not at the facility. The IP was asked what his understanding of the scabies incubation period (the period between exposure to an infection and the appearance of the first symptoms) was. The IP stated the scabies incubation period was a month or a month and a half. The IP stated the IP was not aware of creating a line list for staff because at his previous employment the IP did not do one for a scabies outbreak case and was not told about completing a line list. The IP stated that the Subacute Unit residents at the facility were already on enhanced precautions for C. auris. The IP stated the IP was not aware of the Los Angeles County Department of Public Health Acute Communicable Disease Control Program: Scabies Prevention and Control Guidelines - For Healthcare Settings, July 2019, which stated on page 11, Identify and prepare a line listing of all HCW (healthcare worker) who were direct contacts to a patient/resident or fellow HCW with scabies during the exposure period.
During a review of the facility's policy and procedure (P&P) titled, Scabies - Level III, revised January 2012, the P&P indicated, The purpose of this procedure is to treat residents infected with and sensitized to Sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. The P&P indicated, General Guidelines: Incubation period can be 2-6 weeks before onset of itching for persons with no previous exposure. Symptoms sometimes include severe itching, which worsens at night. Common locations of scabies: anterior axillary region or under breasts, around the waist, between fingers and palm of hand, on the inner thigh, groin, buttocks, anterior surfaces of writs and elbows, upper backs of nursing home residents, and hands of employees. The P&P indicated, Affected residents should remain on Contact Precautions until twenty-four hours after treatment. Family and friends of resident who have had close contact should be notified and given instructions regarding self-examination and treatment. Staff members who may have been exposed should report any rashes developing on their bodies to the Infection Preventionist or Director of Nursing Services. A resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If symptoms are not present, daily assessments should be made until the case has resolved.
During a review of the facility's P&P titled, Policies and Practices, revised July 2014, the P&P indicated, Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The P&P indicated, Prevent, detect, investigate, and control infections in the facility; maintain records of incidents and corrective actions related to infections; all personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.
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
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient Licensed Vocational Nurses (LVNs) and Certified N...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs) provided care and services to residents in accordance with the facility's policy and procedure (P&P) and the Facility Assessment Tool (used by the facility to evaluate what resources are necessary to care for the facility's residents) for four of four sampled residents ( Residents 8, 9, 10 and 11). As a result, Residents 8, 9, 10 did not receive showers. For Resident 8 for not getting up the resident out of bed and into the wheelchair, for Resident 8 and Resident 9 for allowing to sit on soiled adult brief for an extended period of time, and for Resident 11 to wait for assistance from staff for an extended period of time.
These failures had the potential to result in a decline in the residents' physical and psychosocial well-being due to poor quality of care.
Findings:
a. During a review of Resident 8's Face Sheet (FS - document that contains a patient's personal and contact information, diagnoses and medical history), the FS indicated Resident 8 was admitted to the facility on [DATE] with diagnoses which included respiratory failure (when the lungs cannot get enough oxygen into the blood or remove carbon dioxide [waste gas made in the body's cells] from the blood) and contractures (shortening of muscles and stiffening of joints) and wasting away of muscles.
During a review of Resident 8's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/2/2024, the MDS indicated Resident 8's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 8 had impaired movement of both arms and legs. The MDS indicated Resident 8 required substantial/maximal assistance (helper does more than half the effort) from others for oral hygiene, toileting hygiene, and to shower and/or bathe.
b. During a review of Resident 9's FS, the FS indicated Resident 9 was admitted to the facility on [DATE] with diagnoses which included respiratory failure.
During a review of Resident 9's MDS dated [DATE], the MDS indicated Resident 9's cognition was intact. The MDS indicated Resident 9 required substantial/maximal assistance from others for toileting hygiene and to shower and/or bathe.
c. During a review of Resident 10's FS, the FS indicated Resident 10 was admitted to the facility on [DATE] with diagnoses which included functional quadriplegia (affected by or relating to paralysis of all four limbs).
During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10's cognition was intact. The MDS indicated Resident 10 was dependent on others for oral hygiene, toileting hygiene, personal hygiene, for upper and lower body dressing, and to shower and/or bathe.
d. During a review of Resident 11's FS, the FS indicated Resident 11 was admitted to the facility on [DATE] with diagnoses which included respiratory failure and paraplegia (paralysis or severe or complete loss of feeling and movement in the lower half of the body).
During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11's cognition was intact. The MDS indicated Resident 11 was dependent on others for toileting hygiene, for lower body dressing, and to shower and/or bathe.
During a review of the facility's Facility Assessment Tool dated 6/25/2024, the Facility Assessment Tool indicated the staffing plan for the subacute (SA, a level of care needed by a resident who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to most residents in a skilled nursing facility) unit was for one LVN on all shifts to have 12 residents and for CNAs to have 8-10 residents on the day shift (7am-3pm), 10-14 residents on the evening shift (3pm-11pm) , and 19-21 residents on the night shift (11pm- 7am).
During a review of the LVN and CNA assignment for the facility's subacute unit (SA), the LVN and CNA assignment indicated the following:
a. On Thursday, 5/30/2024, the assignment for the day shift indicated there were 55 residents in the SA and there were 3 CNAs working. The assignment indicated CNA 17 had 14 residents, CNA 18 had 14 residents, and CNA 12 had 13 residents.
b. On Thursday, 5/30/2024, the assignment for the evening shift indicated there were 55 residents in the SA and 2 newly admitted residents. The assignment indicated LVN 3, LVN 10, LVN 11, and LVN 12 had 14 residents each and had 2 additional residents each to assist with activities of daily living (ADL, basic self-care tasks which includes bathing or showering, dressing, personal hygiene, getting in and out of bed or a chair, walking, using the toilet, and eating).
c. On Thursday, 5/30/2024, the assignment for the night shift indicated there were 57 residents in the SA. The assignment indicated CNA 8 was the CNA who worked and had 46 residents.
d. On Saturday, 6/1/2024, the assignment for the day shift indicated there were 56 residents in the SA. The assignment indicated LVN 2, LVN 14, LVN 15, and LVN 16 had 14 residents each and had 2 additional residents each to assist with ADLs. CNA 4 and CNA 11 had 23 residents each.
e. On Saturday, 6/1/2024, the assignment for the evening shift indicated there were 56 residents in the SA. The assignment indicated LVN 3 and LVN 18 had 19 residents each, and LVN 17 had 18 residents. LVN 3, LVN 17, and LVN 18 had 2 additional residents each to assist with ADLs. CNA 6 had 56 residents and was training CNA 16.
f. On Sunday, 6/2/2024, the assignment for the evening shift indicated there 57 residents in the SA. The assignment indicated CNA 2 had 22 residents and CNA 6 had 25 residents.
g. On Sunday, 6/2/2024, the assignment for the night shift indicated there were 57 residents in the SA. The assignment indicated there were 4 LVNs on duty and the LVNs had 14 residents each.
h. On Tuesday, 6/25/2024, the assignment for the day shift indicated there were 52 residents in the SA. The assignment indicated there were 3 CNAs on duty. Two CNAs had 13 residents each and one CNA had 12 residents.
During an interview with CNA 2 on 6/26/2024 at 2:52 pm, CNA 2 stated they were usually short staffed in the SA, 2-3 times a week especially on weekends. CNA 2 stated every time CNA 2 had 10 residents or more, CNA 2 would have at least one or two residents whose adult brief would only get changed once for the whole shift.
During an interview with CNA 4 on 6/26/2024 at 3:09 pm, CNA 4 stated whenever CNA 4 had a lot of residents assigned, CNA 4 would not do a second adult brief change on all CNA 4's residents and would not turn all the residents assigned to CNA 4 every two hours.
During an interview with Registered Nurse 3 (RN 3) on 6/26/2024 at 3:48 pm, RN 3 stated CNAs (in general) on the evening shift usually get 8 to 12 residents and get 12 residents each once or twice a week. RN 3 stated 10 residents or less per CNA was ideal. RN 3 stated RN 3's expectation was for all residents' adult brief to be changed 3 times a shift and for all residents to be turned every 2 hours.
During an interview with LVN 4 on 6/26/2024 at 4:13 pm, LVN 4 stated LVNs (in general) had to provide ADL care to residents in addition to their assignment. LVN 4 stated the number of residents assigned to LVNs for ADL care depends on the number of CNAs working. LVN 4 stated LVN 4 had to stop in the middle of medication administration to provide ADL care to residents.
During an interview with Resident 8 on 6/27/2024 at 11:56 am, Resident 8 stated Resident 8's shower days were Tuesday and Friday. Resident 8 stated Resident 8 did not shower last Tuesday, 6/25/2024, because CNA 6 stated there was no time to shower Resident 8. CNA 6 told Resident 8 CNA 6 had 13 residents on 6/25/2024. Resident 8 stated sometimes Resident 8's adult brief would only get changed once a shift and sometimes the adult brief would not get changed at all.
During a review of the facility's Subacute Shower Schedule (SSS) updated 11/7/2023, the SSS indicated Resident 8's shower days were on Tuesdays and Fridays.
During an interview with Resident 10 on 6/27/2024 at 12:27 pm, Resident 10 stated residents (in general) shower only once a week. Resident 10 stated Resident 10 usually shower on Fridays and sometimes on Mondays.
During a review of the SSS updated 11/7/2023, the SSS indicated Resident 10's shower days were on Tuesdays and Fridays.
During an interview with Resident 9 on 6/27/2024 at 12:35 pm, Resident 9 stated Resident 9 showered twice a week. Resident 9 stated, If short staffed, they (CNAs) cannot shower me. They (CNAs) just tell me I can't take a shower because they have a lot of patients. Resident 9 stated the longest wait to be changed after having a bowel movement was an hour.
During a review of the SSS updated 11/7/2023, the SSS indicated Resident 9's shower days were on Tuesdays and Fridays.
During an interview with Resident 11 on 6/27/2024 at 12:42 pm, Resident 11 stated Resident 11 occasionally had to wait for service because there was not enough staff.
During an interview with the facility's Staffer (STF- person in charge of staffing) on 6/28/2024 at 10:52 am, STF stated STF did the staffing for SA. STF stated according to the Director of Staff Development (DSD) the goal for SA was 5 - 6 CNAs on the day shift, 5 CNAs on the evening shift, and 4-5 CNAs on the night shift. STF stated sometimes there were only 2 CNAs or not enough CNAs in the SA because of staff call-off. STF stated the facility has never used staffing registries since STF started doing staffing.
During a concurrent interview and record review with the DSD on 6/28/2024 at 3:30 pm, the DSD stated the goal for full census staffing in the SA was 2 RNs on day and evening shifts and 1 RN on the night shift, 6 LVNs for all shift, 5 CNAs on the day and evening shifts, and 4 CNAs on the night shift. The DSD reviewed the SA assignment for all shifts for 5/30/2024, 6/1/2024, 6/2/2024, and 6/25/2024. The DSD stated having 14 residents and above for LVNs and 13 residents and above for CNAs would make it difficult to provide quality care to the residents.
During a review of the facility's P&P titled, Staffing, dated 10/2017, the P&P indicated the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and facility assessment .
During a review of the facility's P&P titled, Facility Assessment, dated 10/2018, the P&P indicated, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations .Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources available to meet the specific needs of our residents .
May 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
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 follow its Policy and Procedure on Charting and Documentation by fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its Policy and Procedure on Charting and Documentation by failing to document accurately and completely on the Certified Nursing Assistant (CNA) flowsheet the bowel and bladder function and communicate between the interdisciplinary team regarding the resident's condition for 3 of 42 residents in Station 4 (Residents 7, 8 and 9).
This deficient practice had the potential to affect the provision of care and services to the residents and result in adverse consequences for Residents 7, 8 and 9.
Findings:
During a review of Resident 7's Face Sheet (FS), the FS indicated the facility admitted the resident on 5/21/24, with diagnoses that included muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue) and dysphagia (difficulty swallowing).
During a review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/27/24, the MDS indicated Resident 7 had intact cognition (ability to understand). The MDS indicated Resident 7 was dependent with toileting and required set up or clean-up (helper cleans up or sets up, resident completes activity) assistance with eating.
During a review of Resident 7's CNA flowsheet dated 5/2024, there was no documentation on bowel and bladder function for the 11 pm to 7 am shifts on 5/22/24, 5/24/24, 5/25/24, 5/26/24, 5/27/24 and 5/28/24.
During a review of Resident 8's FS, the FS indicated the facility admitted the resident on 5/21/24, with diagnoses that included obstructive and reflux uropathy (a condition in which the flow or urine is blocked) and type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine.)
During a review of Resident 8's MDS dated [DATE], the MDS indicated the resident had intact cognition. The MDS indicated Resident 8 was dependent with toileting and hygiene and required set up or clean-up assistance with eating. The MDS indicated Resident 8 had an indwelling catheter (thin, sterile tube inserted into the bladder to drain urine into a bag outside the body).
During a review of Resident 8s CNA flowsheet dated 5/2024, there was no documentation on bowel and bladder function for the 11 pm to 7 am shifts on 5/23/24, 5/25/24, 5/26/24, 5/27/24, 5/28/24. The CNA flowsheet also indicated there was no documentation on bowel and bladder function for the 7 am to 3 pm shifts on 5/23/24 and 5/28/24.
During a review of Resident 9's FS, the FS indicated the facility admitted the resident on 9/8/23, with diagnoses that included dysphagia and hypertensive chronic kidney disease (a medical condition referring to damage to the kidney due to chronic high blood pressure.)
During a review of Resident 9's MDS dated [DATE], the MDS indicated the resident had intact cognition. The MDS indicated Resident 9 was dependent with toileting and required set up or clean-up assistance with eating.
During a review of Resident 9's CNA flowsheet dated 5/2024, there was no documentation on bowel and bladder function for the 11 pm to 7 am shifts on 5/2/24, 5/4/24, 5/5/24, 5/6/24, 5/7/24, 5/8/24, 5/11/24, 5/13/24, 5/14/24, 5/15/24, 5/20/24, 5/21/24, 5/24/24, 5/2524, 5/26/24, 5/27/24 and 5/28/24. The CNA flowsheet also indicated there was no documentation on bowel and bladder function during the 7 am to 3 pm shifts on 5/10/24, 5/12/24, 5/13/24, 5/14/24, 5/16/24, 5/21/24, 5/23/24, 5/24/24 and 5/25/24.
During an interview on 5/28/24 at 4:54 pm with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Activities of Daily Living (ADL) for all residents needed to be documented on the CNA flowsheet. CNA 1 stated the CNA flowsheet contained information regarding each resident's bowel movement, urine output, turning and repositioning and meal intake.
During an interview on 5/29/24 at 12:50 pm Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated if there was a concern regarding bowel movement then he would refer to the CNA flowsheet. LVN 1 did not answer when asked how LVN 1 would know if a resident had a bowel movement if the resident was unable to verbalize concerns.
During a concurrent interview and record review of the CNA flowsheet for Resident 7, 8 and 9 on 5/29/2024 at 4:00 pm, LVN 2 stated the CNA's (in general) needed to accurately document on the CNA flowsheet because the CNA flowsheet contained information on hygiene, mobility, bowel movements, urination or urine output from urinary catheter, meal intake and turning and repositioning. LVN 2 stated this documentation would keep track of the residents' progress, if the resident had a bowel movement, if the resident urinated or how much was the urine output and how much the resident ate.
During an interview on 5/29/24 at 4:53 pm with Registered Nurse Supervisor 1 (RN Sup 1), RN Sup 1 stated the CAN (in general) needed to document accurately because their documentation could affect patient care.
During an interview on 5/29/24 at 5:26 pm with RN Sup 2, RN Sup 2 stated if CNA documentation was not completed, the nurses would not be able to find the information if there was a bowel or bladder concerns.
During an interview on 5/29/24 at 5:40 pm with the Director of Nursing (DON), the DON stated the CNAs needed to document completely and accurately on the CNA flowsheet and the nurses need to follow up on the completeness of documentation because this would provide information on the resident's condition.
During a review of the facility's Policy and Procedure (P&P) titled Charting and Documentation dated July 2017, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The P&P indicated the medical record shall facilitate communication between the resident's condition and response to care.
May 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report suspected physical abuse within two hours on 5/1/2024 to the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report suspected physical abuse within two hours on 5/1/2024 to the California Department of Public Health (CDPH), local enforcement, and Ombudsman for one of three sampled residents (Resident 1). Resident 1 reported to staff on 5/1/24 that Certified Nursing Assistant 1 (CNA 1) hurt Resident 1 when changing Resident 1 ' s adult brief.
This failure had the potential to result in a delay in investigating potential abuse and expose Resident 1 to further abuse.
Findings:
During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included fibromyalgia (condition that causes pain all over the body), hypothyroidism (conditions when the thyroid gland does not make enough thyroid hormones), and heart failure (condition when the heart does not pump enough blood in the body).
During a review of Resident 1 ' s History and Physical (H&P) dated 12/19/2023, 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 standardized comprehensive assessment of each resident ' s functional capabilities and identifies health problems) dated 2/15/2024, the MDS indicated Resident 1 ' s cognitive abilities (ability to think, learn, and process information) was intact.
During a review of Resident 1 ' s Departmental Notes (DN) dated 5/2/2024 at 5:35 PM, the DN indicated the Social Services Director (SSD) spoke with Resident 1 and Resident 1 stated CNA 1 hurt Resident 1 while providing care on 5/1/2024 at 10:40 PM.
During an interview on 5/7/2024 at 10:43 AM with Resident 1 in Resident 1 ' s room, Resident 1 stated CNA 1 was jabbing her hand down Resident 1 ' s left side when tucking in Resident 1's adult brief. Resident 1 stated Resident 1 told CNA 1 that CNA 1 was hurting her, and stated CNA 1 did it three times and did not say anything to Resident 1. Resident 1 stated Resident 1 reported the incident to Staff Member (SM) 1 when it occurred on 5/1/2024 in the evening.
During an interview on 5/7/2024 at 3:30 PM with SM 1, SM 1 stated Resident 1 reported to SM 1 that CNA 1 physically hurt Resident 1 on 5/1/2024 at night. SM 1 stated SM 1 told Resident 1 that SM 1 did not see any physical signs of abuse on Resident 1. SM 1 stated SM 1 notified the Unit Manager (UM) via text message as SM 1 stated SM 1 did not have enough time to report the incident. SM 1 stated it was not reported within two hours per facility ' s policy and procedure (P&P). SM 1 stated the risk of not reporting within two hours was that the resident can be at risk for getting hurt.
During an interview on 5/7/2024 at 4:02 PM with the UM, the UM stated staff needed to report any allegation of abuse. The UM stated the UM considered the incident between Resident 1 and CNA 1 alleged physical abuse because Resident 1 stated Resident 1 got hurt by CNA 1. The UM stated staff should have reported the incident when staff was made aware of the alleged physical abuse allegation. The UM stated it was late reporting and stated the risk of late reporting was that the resident would be at risk for further harm.
During an interview on 5/7/2024 at 4:28 PM with the Director of Nursing (DON), the DON stated, any and all allegations of abuse needed to be reported within two hours to CDPH, local enforcement, and Ombudsman. The DON stated staff should have reported the incident on 5/1/2024 when staff was made aware of the alleged physical abuse between Resident 1 and CNA 1. The DON stated the risks of late reporting were delays in starting an investigation and safety of the resident.
During a review of the facility ' s Policy and Procedure (P&P) titled, Abuse Reporting and Investigation dated 7/2022, the P&P indicated the facility will report all allegations of abuse as required by law and regulations to the appropriate agencies within two hours.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure hazardous chemicals were kept in a secure area...
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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 hazardous chemicals were kept in a secure area for one of three sampled units, (Unit 3), when one bottle of Melt Down Emulsifier stripper (removing multiple coats of finish from floors), one bottle of Pro-look wet shine floor finish (protects interior floors from stains, scuffs and provides a gloss finish to floors), and two bottles of undercoat sealer (used to seal absorbent surfaces and prevent the topcoat from being absorbed into the surface) were left in an open cart in the hallway, unattended.
This failure had the potential to result in residents in Unit 3 to have access to toxic chemicals and possibly, ingest toxic chemicals and sustain a serious injury.
Findings:
During a concurrent observation and interview on 5/7/2024 at 12:16 PM, two bottles of undercoat sealer, one bottle of Pro-look wet shine floor finish, and one bottle of Melt Down Emulsifier Stripper were placed in an open cart with no lock, unattended, in the hallway outside of room [ROOM NUMBER] in Unit 3. Staff Member 1 (SM 1) was inside room [ROOM NUMBER] standing inside the adjacent bathroom. The cart was not within reach of SM 1. SM 1 stated SM 1 was in the adjacent bathroom of room [ROOM NUMBER] because SM 1 was airing out room [ROOM NUMBER]. SM 1 stated SM 1 had to strip the floor, and stated four bottles were left in the hallway, unattended. SM 1 stated SM 1 needed to use a janitor cart because it has a lock. SM 1 stated the cart SM 1 used did not have a lock and it was easy for any resident to take the hazardous chemicals. SM 1 stated the risk of not using the appropriate cart with a secure storage was that a resident can take and open or swallow the contents of the hazardous chemical.
During an interview on 5/7/2024 at 12:20 PM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated bottles of Melt Down Emulsifier stripper, Pro-look wet shine floor finish, and Undercoat Sealer should not be left unattended and placed in an easily accessible cart. LVN 4 stated Unit 3 was a Memory Care Unit and stated residents in Unit 3 have Dementia (loss of cognitive functioning [ability to think, remember, and reason] that interferes with a person ' s daily life and activities) or Alzheimer ' s disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out simple tasks). LVN 4 stated residents in Unit 3 would be at risk for opening and swallowing the chemicals because of impaired memory or cognition (ability to think).
During an interview on 5/7/2024 at 2:46 PM with the Dietary Supervisor (DS), the DS stated staff members should be using the janitor ' s cart if staff were to transport or use any chemicals on the unit because the cart had a lock. The DS stated chemicals were supposed to be in a safe area and had to be monitored. The DS stated chemicals, especially floor sealant and floor stripper, should not be left in an area that was easily accessible to residents. The DS stated SM 1 should not have used the wired cart and left four bottles of chemicals unattended in the hallway. The DS stated the risk was that the resident could easily grab the chemicals and be at risk for an injury.
During a concurrent interview and record review on 5/7/2024 at 4:28 PM, the facility ' s policy and procedure (P&P) titled, Hazardous Areas, Devices and Equipment, revised 7/2017, was reviewed. The P&P indicated a hazard is defined as anything in the environment that has the potential to cause injury or illness, examples of environmental hazards included but are not limited to access to toxic chemicals. DON stated SM 1 did not follow P&P as chemicals should not be left in the hallway unattended as residents could easily access the chemicals, and possibly sustain a serious injury.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one of five sampled residents (Resident 1) in accordance wit...
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Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one of five sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Homelike Environment, by failing to ensure Resident 1's room walls and ceilings were free of water damage, peeling paint, and discoloration from leaking water when the facility's roof sustained a leak due to rain on 4/17/2024.
This failure had the potential for Resident 1 to be uncomfortable, not have a homelike environment, and be exposed to mold (fungus organism that grows in damp, dim areas) due to water damage that could lead to a decline of health.
Findings:
During a review of Resident 1's Face Sheet (FS- admission record), the FS indicated, the facility initially admitted Resident 1 to the facility on 3/26/2024, and readmitted Resident 1 on 4/10/2024. The FS indicated, Resident 1 had diagnoses of respiratory failure (serious condition that makes it breathe on one's own) and endocarditis (inflammation of the inside lining of the heart chambers and heart valves leading to heart damage).
During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), the MDS indicated, Resident 1 had severely impaired cognition (ability to think, remember, and reason). The MDS indicated, Resident 1 was dependent (helper did all of the effort; resident did none of the effort to complete the activity, or the assistance of 2 or more helpers was required for the resident to complete the activity) on staff for eating, oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, rolling left to right, chair/bed to chair transfers, tub/shower transfers, and car transfers. The MDS indicated, the activity was not attempted due to medical condition or safety concerns for sitting to lying, lying to sitting on side of bed, sitting to standing, and toilet transfers.
During a concurrent observation and interview on 4/30/2024 at 1:20 pm with the Maintenance Assistant (MA), inside of Resident 1's room, Resident 1's room was observed. The MA stated there was obvious discoloration to the wall and ceiling above the sliding glass window. The MA stated the discoloration was a brown-like, rust color. The MA stated there were pieces of ceiling missing and holes in the ceiling due to maintenance drilling holes in the ceiling to drain water from a leak that happened approximately one week prior to interview (unable to recall exact date). The MA stated there were cracks and stains in the wall because there was a leak and water came out of the walls. The MA stated two days after the leak was found, the roof was repaired. The MA stated Resident 1's room did not promote a homelike environment because of the condition of the wall and ceiling from the leak. The MA stated they had not been able to repair the wall or ceiling in Resident 1's room because, They had too much to do.
During a concurrent observation and interview on 4/30/2024 at 1:38 pm with the MA, inside of Resident 1's room, Resident 1's room walls and ceilings were observed. The MA stated the ceiling hole in Resident 1's room was dry. The MA stated the dried paint had the potential to chip and crack and fall on the floor, on Resident 1, or Resident 1's belongings.
During an interview on 4/30/2024 at 1:44 pm with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 1 was currently not in Resident 1's room due to Resident 1 being out of the facility for an appointment. RNS 1 stated the water damaged wall and ceiling in Resident 1's room could potentially affect Resident 1 because the paint could chip on Resident 1's bed or Resident 1. RNS 1 stated a water leak could cause mold to grow and could make Resident 1 sick and lead to a decline in health. RNS 1 stated Resident 1 was at risk for infection because Resident 1 was on dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to).
During an interview on 4/30/2024 at 1:52 pm with the Maintenance Supervisor (MS), the MS stated if there was a roof leak from the rain, it was possible mold could grow into Resident 1's wall and ceiling and potentially make Resident 1 sick. The MS stated the MS was not sure if the damaged wall and ceiling promoted a homelike environment for Resident 1. The MS stated the MS had not repaired the wall and ceiling because the MS, Had a lot on the to-do list.
During an interview on 4/30/2024 at 4:49 pm with the Administrator (ADM), the ADM stated all resident rooms should be clean, safe, and free from water damage from leaks. The ADM stated if rooms did not feel like a homelike environment, it could negatively affect the resident.
During a review of the facility's P&P titled, Homelike Environment, revised in 2/2021, the P&P indicated, residents were provided a safe, clean, comfortable, and homelike environment, and were encouraged to use their personal belongings to the extent possible. The P&P indicated, facility staff and management maximized, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting that included, a clean, sanitary, and orderly environment.
Apr 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to properly maintain the bed frame for two out of three sampled residents (Resident 1 and Resident 3) by failing to:
Inspect and ...
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Based on observation, interview, and record review the facility failed to properly maintain the bed frame for two out of three sampled residents (Resident 1 and Resident 3) by failing to:
Inspect and ensure Resident 1 and Resident 3's bed frame did not have any chipped wood and was in good condition.
This deficient practice had the potential for Resident 1 and Resident 3 to sustain injuries and feel their environment was not homelike.
Findings:
During an observation on 4/10/24 at 11:58 am, a small portion of the bed frame was missing and had chipped wood on Resident 3's right side of the footboard of Resident 3's bed frame. Resident 3 stayed in the same room and used the same bed after Resident 1 was discharged from the facility.
During a concurrent observation and interview with the Maintenance Supervisor (MS) on 4/10/24 at 12:09 pm, MS stated Resident 3's footboard of the bed frame was cracked. MS stated Resident 3's bed frame was not supposed to be like that and needed to be changed. MS stated MS would get on the phone to order a new one. MS stated that MS changed the broken beds when they break.
During a concurrent observation and interview with the Lead Licensed Vocational Nurse 1 (LLVN 1) on 4/11/24 at 11:08 am, Resident 3's bed no longer had chipped wood on the footboard of the bed frame. LLVN 1 stated LLVN 1 changed it and it was a brand new bed.
During a review of the facility's policy and procedure (P&P), titled Quality of Life- Homelike Environment, revised in 2017, the P&P indicated that residents were provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The P&P indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting. The P&P indicated those characteristics included a clean bed and bath linens that were in good condition.
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 F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure call lights were answered in a timely manner an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure call lights were answered in a timely manner and/or within reach for four of four sampled residents (Residents 3, 4, 2, and 5) in accordance with the facility's policy and procedures (P&P) titled, Answering the Call Light and Call System, Resident.
These deficient practices had the potential for Residents 3, 4, 2, and 5 to not receive assistance when needed which could result in harm, physical injury, and/or death.
Findings:
1. During a review of Resident 3's Face Sheet (FS), the FS indicated, the facility admitted Resident 3 on 4/01/2024, with diagnoses that included wedge compression fracture (the fracture occurs when the bone actually collapses and the front part of the vertebral [bones that make up the spine] body forms a wedge shape) of T11-T12 (bones in the middle section of the spine) vertebra and parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors [shaking or trembling]).
During a review of Resident 3's admission Assessment (AA), dated 4/01/2024, the AA indicated Resident 3 was alert, able to follow simple commands, able to make needs known, and able to understand others.
During a concurrent observation and interview on 4/10/2024 at 12:03 pm, in the presence of Lead Licensed Vocational Nurse 1 (LLVN 1), Resident 3 was observed with tremors and lying slightly turned to Resident 3's right side. Resident 3's call light was observed on Resident 3's left side but on the floor. Resident 3 was observed with a curved upper back and there was a gap between the pillow and Resident 3's upper back. Resident 3 called to LLVN 1 to raise the bed. LLVN 1 stated the call light should have been with Resident 3 and not on the floor.
2. During a review of Resident 4's FS, the FS indicated, the facility readmitted Resident 4 on 9/28/23, with diagnoses that included unstageable pressure ulcer ([PU] localized damage to the skin and underlying soft tissue, usually over a bony prominence (areas where bones are close to the surface) or related to a medical or other device, resulting from sustained pressure) of sacral ([sacrum] a triangular bone at the base of the spine]) region, muscle wasting and atrophy (wasting or thinning of muscle mass), and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease).
During a review of Resident 4's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 1/16/24, the MDS indicated Resident 4 had intact cognition (ability to think and process information).
During an interview on 4/10/24 at 3:51 pm, Resident 4 stated that Resident 4 waited for a long time every now and then to receive assistance. Resident 4 stated the wait time could range from 20 to 30 minutes. Resident 4 stated Resident 4 pushed the call light to be changed. Resident 4 stated this happened often and on every shift.
3. During a review of Resident 2's FS, the FS indicated, the facility readmitted Resident 2 on 12/23/23, with diagnoses that included dysphagia (difficulty swallowing), lymphedema (swelling due to build-up of lymph fluid [The clear fluid that travels through the lymphatic system and carries cells that help fight infections and other diseases] in the body, and history of falling.
During a review of Resident 2's admission MDS, dated [DATE], the MDS indicated Resident 2 had intact cognition. The MDS indicated Resident 2 was dependent (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) for toileting hygiene and showering/bathing. The MDS indicated Resident 2 required substantial/maximal assistance for rolling left to right (the ability to roll from lying on back to left and right side and return to lying on back on the bed).
During an observation on 4/11/24 at 12:13 pm, call lights were observed for Rooms 603, 608, 609, and 614.
During an observation and interview with Resident 2 on 4/11/24 at 12:13 pm, Resident 2's call light was on. Resident 2 stated Resident 2 had been calling for assistance. Resident 2 stated Resident 2's neck was hurting and would like to be repositioned. Resident 2 stated Resident 2 pressed the call light twice and had been waiting for 40 to 50 minutes. Resident 2 stated she tried to ask the staff a question, but they walked away and they did not come back. Resident 2 stated, You have to take time with people.
During a concurrent observation and interview with 4/11/24 at 12:27 pm, Registered Nurse 2 (RN 2) answered Resident 2's call light after 14 minutes and repositioned Resident 2.
During an observation at 12:29 pm, after being on for 16 minutes, call lights were still on for room [ROOM NUMBER] and 609.
During an interview with a certified nursing assistant 1 (CNA 1), on 4/11/24 at 2:24 pm, CNA 1 stated CNA 1 answered the call light on time if CNA 1 was available. CNA 1 stated if CNA 1 saw the call light, CNA 1 answered the call light right away. CNA 1 stated everybody was responsible for answering call lights. CNA 1 stated if CNA 1 did not answer a call light right away, an emergency could happen and that was not good.
4. During a review of Resident 5's FS, the FS indicated, the facility readmitted Resident 5 on 10/14/23, with diagnoses that included Type 2 Diabetes Mellitus ([DM] adult-onset diabetes which was characterized by high levels of sugar in the blood), respiratory failure (when the lungs can't get enough oxygen into the blood), and obesity.
During a review of Resident 5's Quarterly MDS dated [DATE], the MDS indicated Resident 5 had intact cognition.
During an interview with Resident 5 on 4/12/24 at 2:04 pm, Resident 5 stated the staff did not answer the light sometimes. Resident 5 stated it could be something simple. Resident 5 stated if it was something like Resident 5 could not breathe, that could be a problem.
During an interview with LLVN 1 on 4/12/24 at 2:18 pm, LLVN 1 stated everyone could answer the call light. LLVN stated if a call light was not answered timely, a resident could get hurt.
During a review of the facility's P&P titled, Answering the Call Light, revised in 10/2010, the P&P indicated the purpose of this procedure was to respond to the resident ' s requests and needs. The P&P indicated, when the resident was in bed or confined to a chair be sure the call light was within easy reach of the resident.
During a review of the facility's P&P titled, Call System, Resident, dated 9/2022, the P&P indicated calls for assistance were answered as soon as possible, but no later than 5 minutes. The P&P indicated that urgent requests for assistance were addressed immediately.
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 F0687
(Tag F0687)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide treatment and care to maintain foot health for one of four sampled residents (Resident 2) by failing to:
1. Ensure Ce...
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Based on observation, interview, and record review, the facility failed to provide treatment and care to maintain foot health for one of four sampled residents (Resident 2) by failing to:
1. Ensure Certified Nursing Assistant (CNA) 1 and/or Licensed Vocational Nurse (LVN) 1 provided nail care to Resident 2 as indicated in the facility ' s policy and procedure (P&P) titled, Fingernails/Toenails, Care of.
2. Ensure Social Service Designee (SSD) 2 arranged podiatry services (services provided by a podiatrist [a health professional trained to diagnose and treat diseases and other disorders of the feet]) for Resident 2 as indicated in Resident 2's care plan titled Baseline Care Plan.
3. Develop a comprehensive resident-centered care plan for foot care for Resident 2 as indicated in the facility's policy and procedure (P&P) titled, Care Plans - Comprehensive.
These deficient practices had the potential to cause inconsistent care and services provided to Resident 2 and could cause pain and podiatric complications for Resident 2.
Findings:
During a review of Resident 2's Face Sheet (FS), the FS indicated, the facility admitted Resident 2 on 12/23/2023, with diagnoses that included acute embolism (a sudden blocking of an artery [a blood vessel that carried blood from the heart to tissues and organs in the body]) and thrombosis (the formation of a blood clot inside blood vessels) of deep veins of left upper extremity (limb of the body such as the arm or leg), rhabdomyolysis (a condition that caused muscles to break down which led to muscle death), and malignant neoplasm (a tumor that had spread locally and/or to distant sites) of axilla (underarm) and upper limb lymph nodes (small bean shaped structures that contain white blood cells, which fight infection).
During a review of Resident 2's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 12/29/2023, the MDS indicated, Resident 2 had intact cognition (ability to think, remember, and reason) and was able to understand and be understood by others. The MDS indicated, Resident 2 required substantial/maximal assistance (helper lifted or held trunk or limbs and provided more than half the effort) with upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene.
During a review of Resident 2's admission Assessment (AA), dated 12/23/2023, the AA indicated, Resident 2 had bilateral (affecting both sides) hammer toes (changes in toe joints that made the toe joins point up instead of lying flat), dry skin, and curved long toenails.
During a review of Resident 2's care plan titled, Baseline Care Plan (BCP), dated 12/23/2023, the BCP indicated, social service to provide podiatry services for Resident 2.
During a review of Resident 2's Skilled Nursing Facility admission History and Physical (H&P, a formal and complete assessment of the resident by a physician), dated 12/24/2023, the H&P indicated, Resident 2 was alert, oriented, followed instructions, and answered questions. The H&P indicated, all of Resident 2's toenails were very long, curved, and dystrophic (deformed, thickened, or discolored). The H&P indicated, Resident 2 needed podiatry care when stable (no acute change in resident's condition or not deteriorating in health). The H&P indicated, Resident 2 was to have proper foot care and skin care for now.
During a review of Resident 2's Physician's Orders (PO), for the month of April 2024, the PO indicated, there was no order for podiatry consult.
During a review of Resident 2's Care Plans (CP), the CP indicated, there was no care plan for Resident 2's feet and toenails.
During a concurrent observation and interview on 4/10/2024 at 12:27 pm, in the presence of Lead Licensed Vocational Nurse (LLVN) 1, Resident 2's feet was observed to have yellowish, thick, long, and curved toenails. Resident 2 stated Resident 2 had been trying to get someone to help cut the toenails but no one in the facility was responding to Resident 2.
During a concurrent observation and interview on 4/11/2024 at 12:13 pm, Resident 2 stated nobody had looked at Resident 2's feet since admission to the facility in December 2023. Resident 2 verbalized the pain on the feet was ten out of ten on the pain scale (zero was considered no pain; one to three was mild pain; four to six was moderate pain; seven to ten was severe pain). Resident 2 stated the pain happened every day. Resident 2 stated, I have pain so bad, I holler. Resident 2 was observed crying and verbalized, I have gotten to a point now that I told the CNA, you all do not care about me. Are you all prejudice? What did I do to deserve this?
During an interview on 4/11/2024 at 2:15 pm with Certified Nursing Assistant (CNA) 1, CNA 1 stated when CNA 1 took care of Resident 2, approximately two months ago, CNA 1 remembered Resident 2 had long toenails. CNA 1 stated CNA 1 reported Resident 2's long toenails to Licensed Vocational Nurse 1 (LVN 1) at the time. CNA 1 stated during the time CNA 1 took care of Resident 2, CNA 1 reported the long toenails twice, two weeks apart, to LVN 1 because CNA 1 had noticed nothing was done to Resident 2's toenails.
During an interview on 4/11/2024 at 2:47 pm with LVN 1, LVN 1 stated Resident 2's toenails were long. LVN 1 stated LVN 1 informed Medical Doctor (MD) 1 at the time CNA 1 reported it to LVN 1, but LVN 1 was not sure it was documented in Resident 2's chart. LVN 1 stated if it was not documented, it meant nothing was done.
During an interview on 4/12/2024 at 10:35 am with MD 1 stated Resident 2 was admitted to the facility with very long toenails. MD 1 stated when Resident 2 transitioned to custodial care (non-medical care that helps individuals with activities of daily living [ADL] such as bathing, dressing, and grooming) and Resident 2's condition stabilized, MD 1 informed the facility staff to put Resident 2 on the list for podiatry care. MD 1 stated this happened about two or three months ago when MD 1 mentioned it during a weekly meeting in the presence of social services department.
During an interview on 4/12/2024 at 12:45 pm with SSD 2, SSD 2 stated custodial residents were being seen by podiatry. SSD 2 stated social services department determined when a resident needed podiatry services by looking through the residents' charts and when the nursing staff informed them. SSD 2 stated SSD 2 was not sure if Resident 2 was seen by podiatry. SSD 2 stated Resident 2 was placed in custodial care at the end of February 2024. SSD 2 stated even though Resident 2 was under custodial care, Resident 2 should have been seen by podiatry. SSD 2 stated not being seen by podiatry put Resident 2 at risk for pain.
During an interview on 4/12/2024 at 1:34 pm and at 3:07 pm with the Director of Nursing (DON), the DON stated different staff members at different times were responsible for checking on residents' toenails. DON stated CNAs who do daily care should report to the licensed nurse if CNAs ever saw anything out of the ordinary during care and during residents' shower days. The DON stated long nails on residents should not be happening because at some point the nails would curl. The DON stated the skin would be impaired and it could cause pain. The DON stated the facility needed to develop a care plan for Resident 2's feet/toenails to be able to take care of Resident 2's needs.
During a review of the facility's P&P titled, Care Plans - Comprehensive, revised in September 2010, the P&P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.
During a review of the facility's P&P titled, Fingernails/Toenails, Care of, revised in February 2018, the P&P indicated the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Review the resident's care plan to assess for any special needs of the resident. Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.
Mar 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to secure and protect the personal belongings of one of three sampled residents (Resident 1) from loss or theft.
This deficient practice had t...
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Based on interview and record review, the facility failed to secure and protect the personal belongings of one of three sampled residents (Resident 1) from loss or theft.
This deficient practice had the potential to result in loss or theft of other residents ' personal belongings in the facility.
Findings:
During a review of Resident 1's Face Sheet (FS), the FS indicated the facility re-admitted Resident 1 to the facility on 2/3/2024 with diagnoses that included encephalopathy (a change in one ' s brain function due to injury or disease), dysphagia (difficulty swallowing), and respiratory failure (a serious condition that makes it difficult to breathe on your own).
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/27/2024, the MDS indicated, Resident 1 was understood by others and had the ability to understand others.
During an interview on 3/6/2024 at 12:29 pm, with Resident 1, Resident 1 stated she was missing personal items, which was reported to the staff last month, in February 2024. Resident 1 also stated a family friend had dropped off food items last month to the facility ' s receptionist and Resident 1 never received the food items. Resident 1 stated the facility kept asking her to produce a receipt for the items, which Resident 1 did not have.
During an interview on 3/7/24 at 2:27 pm, with Receptionist Staff 1 (RS 1), RS 1 stated there was no log or list to keep track of deliveries or drop offs at the facility. RS 1 stated if a family member dropped off items for a resident, RS 1 would just contact nursing staff from the nurses ' station to go to the lobby to pick up the items for the resident.
During an interview on 3/7/24 at 2:34 pm, with Registered Nurse 2 (RN 2), RN 2 stated some family members have complained in the past about not finding any of the items the family members had brought to the facility. RN 2 stated the certified nursing assistants (CNAs) would just tell the residents that the CNAs were unable to find the items.
During an interview on 3/7/24 at 3:09 pm, with Receptionist Staff 2 (RS 2), RS 2 stated she did not exactly remember if anyone dropped off items for Resident 1. RS 2 stated the facility receives a lot of deliveries and drop offs all the time. RS 2 stated if family members dropped off items, RS 2 usually just called the nurses ' station for staff to pick up the items from the lobby to take back to the resident.
During an interview on 3/7/2024 at 3:05 pm, with Social Services Designee 1 (SSD 1), SSD 1 stated it was important to have a system to track how resident ' s items were being dropped off by family members at the facility and how they were being given to the residents.
During an interview on 3/7/2024 at 4:04 pm, with RN 1, RN 1 stated it was important to keep track of resident ' s belongings, so staff know that the belongings are only for that resident ' s personal use.
During a review of the facility ' s P&P titled, Personal Property, revised in August 2022, the P&P indicated resident belongings are treated with respect by facility staff, regardless of perceived value. The P&P indicated the resident ' s personal belongings are inventoried and documented upon admission and updated as necessary. The facility promptly investigates any complaints of misappropriation or mistreatment of resident property.
During a review of the facility ' s undated P&P titled, Theft and Loss Policy and Procedure, the P&P indicated it is the policy of the facility that any theft or loss of a resident ' s personal property will be reported to the charge nurse at the nursing station or directly to the social services director. The report will be submitted to the social services director within 24 hours of the reported loss. The Administrator is responsible for seeing that action is taken on all reports of theft or loss. The social services director is responsible for seeing that all reports are logged on the theft and loss log and maintained in the social services director ' s office.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide adequate supervision to ensure safety and prevent elopement (to leave or run away) of one of three sampled residents (Resident 2).
...
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Based on interview and record review, the facility failed to provide adequate supervision to ensure safety and prevent elopement (to leave or run away) of one of three sampled residents (Resident 2).
This deficient practice had the potential to affect Residents 2's safety and increase the risk for injury and/or death.
Findings:
During a review of Resident 2's Face Sheet (FS), the FS indicated the facility admitted Resident 2 on 11/10/2023 with diagnoses that included metabolic encephalopathy (a disorder where medical problems such as blood infections or liver or kidney failure cause brain damage), dementia (loss of memory and other mental abilities severe enough to interfere with daily life), and type 2 diabetes mellitus (characterized by high levels of blood sugar in the blood).
During a review of Resident 2's Care Plan (CP) for elopement, dated 11/13/2023, the CP indicated, Resident 2 was at risk for injuries secondary to (relating to) elopement. The CP indicated Resident 2 had the potential for elopement due to cognitive impairment (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions). The CP indicated Resident 2 was seeking (searching) exit doors and wandering. The CP indicated for staff to monitor Resident 2 ' s location with frequent visual checks at least every two hours and to keep Resident 2 in the locked/memory unit (a specific area of the facility that has a restricting device separating the residents in the unit from the residents in the remainder of the facility) with secured doors.
During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/14/2024,the MDS indicated, Resident 2 usually had the ability to understand and was usually understood by others. The MDS indicated Resident 2 had wandering (to walk around slowly often without any particular sense of purpose or direction) behavior that occurred four to six days, but less than daily.
During a review of Resident 2 ' s SBAR (Situation, Background, Assessment, Recommendation), dated 3/2/2024 at 4:02 pm, the SBAR indicated, on 3/2/2024 at approximately 12:30 pm, staff noticed Resident 2 was not in his room in the locked/memory unit and Resident 2 was not in the facility. The SBAR indicated Resident 2 was found walking outside of the facility near a gas station.
During an interview on 3/7/2024 at 1:32 pm, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated when entering and/or exiting the locked/memory unit, staff had to enter a code for the secured doors to open. LVN 1 stated Resident 2 may have followed some visitors out of the secured doors when they were opened. LVN 1 stated staff should have been more observant of Resident 2. LVN 2 stated there were times when all staff members in the locked/memory unit were with other residents and no one was watching the doors. LVN 2 stated it was important to monitor the doors because an accident could have happened to Resident 2.
During an interview on 3/7/2024 at 4:04 pm, with Registered Nurse 1 (RN 1), RN 1 stated staff in the locked/memory unit should have been watching the door and made sure the door was closed. RN 1 stated residents in the locked/memory unit had to be monitored because the residents on the unit were exit seeking and at risk for elopement.
During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, revised in July 2017, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment.
During a review of the facility ' s P&P titled, Wandering and Elopements, revised in March 2019, the P&P indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If an employee observes a resident leaving the premises, he/she should attempt to prevent the resident from leaving in a courteous manner; get help from other staff members in the immediate vicinity, if necessary; and instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure social services was provided for one of three sampled residents (Resident 1) to resolve Resident 1 ' s grievance (a complaint) relat...
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Based on interview and record review, the facility failed to ensure social services was provided for one of three sampled residents (Resident 1) to resolve Resident 1 ' s grievance (a complaint) relating to missing personal items.
This deficient practice had the potential to cause Resident 1 emotional and psychological (related to the mental and emotional state of a person) distress (a feeling of extreme worry, sadness, or pain).
Findings:
During a review of Resident 1's Face Sheet (FS), the FS indicated the facility most recently re-admitted Resident 1 on 2/3/2024 with diagnoses that included encephalopathy (a change in one ' s brain function due to injury or disease), dysphagia (difficulty swallowing), and respiratory failure (a serious condition that makes it difficult to breathe on your own).
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/27/2024, the MDS indicated, Resident 1 was understood by others and had the ability to understand others.
During an interview on 3/6/2024 at 12:29 pm, with Resident 1, Resident 1 stated she had missing personal items which was reported to the staff last month, in February 2024. Resident 1 expressed grief due to the lack of response from the social services department. Resident 1 stated, They never show up. I am tired of it.
During an interview on 3/6/24 at 1:36 pm, with the Director of Social Services (DSS), DSS stated DSS was not aware of any missing items reported to the social services department.
During an interview on 3/6/2024 at 2:25 pm, with Resident 1, in the presence of Social Services Designee 1 (SSD 1), Resident 1 stated, I feel like I do not have a social worker. I have given up on this place.
During an interview on 3/7/24 at 2:34 pm, with Registered Nurse 2 (RN 2), RN 2 stated she was aware that Resident 1 was missing personal items and stated it was reported to the social services department last month in February 2024.
During a review of the facility ' s list of duties and responsibilities for the director of social services, the list indicated social services department was responsible to review complaints and grievances made by the resident and make a written/oral report to the administrator indicating what action(s) were taken to resolve the complaint or grievance and to follow the facility ' s established procedures.
During a review of the facility ' s policy and procedure (P&P) titled, Social Services, revised in September 2021, the P&P indicated the facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The P&P indicated the social worker/social services staff are responsible for being knowledgeable about the rights of residents in accordance with federal requirements, including resident rights, assisting residents in voicing, and obtaining resolution to grievances about treatment, living conditions, visitation rights and accommodation of needs, and making arrangements for obtaining needed items such as personal items.
During a review of the facility ' s undated P&P titled, Theft and Loss Policy and Procedure, the P&P indicated it is the policy of the facility that any theft or loss of a resident ' s personal property will be reported to the charge nurse at the nursing station or directly to the social services director. The report will be submitted to the social services director within 24 hours of the reported loss. The Administrator is responsible for seeing that action is taken on all reports of theft or loss. The social services director is responsible for seeing that all reports are logged on the theft and loss log and maintained in the social services director ' s office.
Feb 2024
4 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Notification of Changes
(Tag F0580)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to promptly (quickly/timely) notify the physician for one of three sampled re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to promptly (quickly/timely) notify the physician for one of three sampled residents (Resident 1) who experienced a change of condition (COC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) as indicated in Resident 1's Care Plan titled, Atrial Fibrillation (A-fib- irregular and often very rapid heart rhythm) and the facility's policies and procedures titled, Resident Examination and Assessment, and Change in a Resident's Condition or Status, by failing to:
1. Ensure Licensed Vocational Nurse (LVN) 5, LVN 6, LVN 7 and LVN 8 notified Resident 1's Primary Physician (PP)/Medical Doctor (MD 1), on 12/3/2024 at 9 pm, 12/4/2024 at 9 am and 9 pm, 12/5/2024 at 9 am, 12/7/2024 at 9 am, and 12/8/2023 at 9:00 am when LVN 5, LVN 6, LVN 7, and LVN 8 held (did not give/administer) Resident 1's amiodarone (medication used to treat certain types of abnormal heart rhythms that have not improved with other medications) and labetalol (medication used to treat high blood pressure) when Resident 1's heartrate (HR- heart beat/pulse) was below 60 beats per minute (BPM)(Normal HR was between 60 BPM to 100 BPM).
2. Ensure LVN 5 notified MD 1 instead of Resident 1's nephrologist (MD 2, a medical doctor who specialized in kidney care and treating diseases of the kidneys) who was seeing Resident 1 for the very first time on 12/8/2023 at 3:24 pm, when Resident 1's HR dropped to 46 BPM and Resident 1 appeared comatose.
As a result, on 12/8/2023, from 9:00 am to 5:30 pm, Resident 1 experienced sustained bradycardia (continued HR below 60 BPM) and Resident 1's HR dropped to as low as 42 BPM. Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1's Intensive Care Unit (ICU- unit in hospital providing intensive care for critically ill or injured residents/patients) on 12/8/2023 at 5:31 pm for further evaluation and treatment.
Cross Reference F656
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE] with diagnoses that included atrial fibrillation, ventilator dependence (dependent on mechanical life support to sustain daily respiration for any part of the day), and heart failure (a condition in which the heart muscle is unable to pump blood as well as it should). The AR indicated, MD 1 was Resident 1's PP.
During a review of Resident 1's admission Assessment (AA), dated 11/13/2023, timed at 7 pm, the AA indicated, Resident 1 had an irregular pulse rhythm (abnormal heartbeat).
During a review of Resident 1's Care Plan (CP) titled, Atrial Fibrillation, dated 11/13/2023, the CP indicated, Resident 1 was at risk for irregular pulse/irregular heartbeat, chest pain, and shortness of breath (SOB) due to A-fib. The CP indicated, for staff to monitor Resident 1 for chest pain or abnormal HR and report to the physician.
During a review of Resident 1's Physician Orders (PO), dated 11/13/2023, the PO indicated to administer amiodarone hydrochloride (HCL) 100 milligrams (mg- unit of measurement) tablet, give one (1) tablet by gastrostomy tube (GT- tube inserted through the stomach to deliver nutrition and/or medication) every 12 hours for A-fib and hold (do not give) amiodarone for a HR less than (<) 60 BPM.
During a review of Resident 1's PO, dated 11/17/2023, the PO indicated to administer labetalol HCL 100 mg tablet, give 1 tablet by GT every 12 hours at 9 am and 9 pm for hypertension, and hold labetalol for systolic blood pressure (SBP- top number of the blood pressure reading; pressure in the arteries when the heart beats) of 110 millimeters of mercury (mmHg, unit of measurement) or HR < 60 BPM.
During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 11/17/2023, the MDS indicated, Resident 1 was not in a persistent vegetative state (complete unawareness of self and environment accompanied by sleep-wake cycle) or no discernible consciousness (coma). The MDS indicated, Resident 1 had severely impaired cognition (ability to think, remember, and function). The MDS indicated, Resident 1 was dependent (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, and personal hygiene.
During a review of Resident 1's Medication Administration Record (MAR- a report that serves as a legal record of the medications administered to a resident) for December 2023, the MAR indicated the following:
1. LVN 6 held the amiodarone and labetalol on 12/3/2024 at 9 pm for HR of 56 BPM.
2. LVN 7 held the amiodarone and labetalol on 12/4/2024 at 9 am for HR of 59 BPM.
3. LVN 6 held the amiodarone and labetalol on 12/4/2024 at 9 pm for HR of 58 BPM.
4. LVN 7 held the amiodarone and labetalol on 12/5/2024 at 9 am for HR of 58 BPM.
5. LVN 8 held the amiodarone and labetalol on 12/7/2024 at 9 am for HR of 58 BPM.
6. LVN 5 held the amiodarone and labetalol on 12/8/2024 at 9 am for HR of 50 BPM.
During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations), dated 12/8/2023, timed at 3:24 pm, the SBAR indicated, Resident 1's HR was 46 BPM. The SBAR indicated, Resident 1's blood pressure (BP- the pressure circulating blood against the walls of blood vessels; abnormal BP was less than 120/80 mmHg and above140/90 mmHg was considered high blood pressure) was 149/90 mmHg. The SBAR indicated, Resident 1 appeared comatose (state of deep unconsciousness for a prolonged or indefinite period because of severe illness or injury). The SBAR indicated, LVN 5 notified Resident 1's nephrologist (MD 2) on 12/8/2023 at 3:24 pm regarding Resident 1 had a HR of 46 BPM.
During a review of Resident 1's Departmental Notes (DN), dated 12/8/2023, timed at 7:33 pm, the DN indicated, (on 12/8/2023) at 3:30 pm, MD 2 evaluated/assessed Resident 1. The DN indicated, Resident 1's BP was 168/91 mmHg and HR was 46 BPM. The DN indicated, MD 2 ordered to transfer Resident 1 to GACH 1 for further evaluation and treatment if Resident 1 sustained a low HR. The DN indicated, (on 12/8/2023) at 5:01 pm, Resident 1's HR was 42 BPM. Registered Nurse Supervisor (RNS) 1 notified MD 2 and MD 2 ordered to transfer Resident 1 to GACH 1. The DN indicated, RNS 1 called 911 (emergency medical services) and paramedics (healthcare professional trained to give emergency medical care to people who are injured or ill outside of a hospital) arrived at the facility at 5:07 pm. The DN indicated, Resident 1 left the facility at 5:20 pm.
During a review of Resident 1's GACH 1 Emergency Department Physician Note (EDPN), dated 12/8/2023, timed at 5:31 pm, the EDPN indicated, Resident 1 presented in the emergency room with persistent (continuing firmly) and significant (important and deserving attention) bradycardia with HR in the 40's BPM. The EDPN indicated, Resident 1 had elevated troponin (protein found in heart muscle that leaks into the blood stream within 6 hours after a heart attack). The EDPN indicated, Resident 1 had sustained a non-ST elevated myocardial infarction (NSTEMI- type of heart attack that happens when the heart's need for oxygen cannot be met), and acute-on-chronic- kidney injury (medical emergency characterized by rapid fall in kidney function). The EDPN indicated, Resident 1 was admitted to the ICU for post-stabilization care (covered services, related to an emergency medical condition that are provided after a patient was stabilized to maintain the stabilized condition).
During a review of Resident 1's GACH 1 Discharge Summary (DS), dated 12/27/2023 at 4:06 am, the DS indicated, Resident 1 was admitted to the ICU with acute-on-chronic respiratory failure (occurs suddenly and emergently from injury or illness, that makes it difficult to breathe on one's own), sepsis (the body's extreme response to infection and is a life-threatening medical emergency), and NSTEMI. The DS indicated, Resident 1 was not improving and was unresponsive (unable to react or respond to stimuli due to injury, illness, or the dying process) in a comatose state. The DS indicated, Resident 1 had minimal brain activity. The DS indicated, Resident 1 was put on comfort care (physical, emotional, social, and spiritual support for patients and their families).
During an interview on 2/8/2024 at 10:39 am with LVN 3, LVN 3 stated abnormal vital signs (VS- measurements of the body's most basic functions consisting of body temperature, pulse [HR], respiratory [breathing] rate, blood pressure, and oxygen levels) were considered as COC. LVN 3 stated when a resident (in general) had a COC, LVN 3 would complete a SBAR and notify the resident's physician (in general) and report all findings promptly.
During an attempted telephone interview on 2/8/2024 at 12:30 pm with RNS 1, RNS 1 was not available and did not return the call.
During a concurrent telephone interview and record review on 2/8/2024 at 6:45 pm with MD 1, Resident 1's MAR for the month of December 2024 and the SBAR dated 12/8/2023 were reviewed. MD 1 stated MD 1 was Resident 1's PP; However, LVN 5, 6, 7, and 8 did not notify MD 1 of Resident 1's HR below 60 BPM and when the LVNs (LVN 5, 6, 7, and 8) held amiodarone and labetalol to Resident 1 due to Resident 1's HR was below 60 BPM (on 12/3/2024 at 9 pm, 12/4/2024 at 9 am and 9 pm, 12/5/2024 at 9 am, 12/7/2024 at 9 am, and 12/8/2024 at 9 am). MD 1 stated LVN 5 did not notify MD 1 of Resident 1's change of condition on 12/8/2023 at 3:24 pm. MD 1 stated LVN 5 notified MD 2. MD 1 stated a facility staff (unidentified) notified MD 1 of Resident 1's COC when Resident 1 was transferred to GACH 1 via 911 (on 12/8/2023 at around 5:20 pm). MD 1 stated MD 2 is a nephrologist and MD 2 first saw Resident 1 at the facility on 12/8/2023. MD 1 stated if the facility had notified MD 1 of Resident 1's bradycardia, MD 1 would have ordered to transfer Resident 1 to GACH 1 right away due to Resident 1's comorbidities (more than one disease/condition is present in a person at the same time and associated with worse health outcomes and more complex clinical management).
During a telephone interview on 2/8/2024 at 7:16 pm with LVN 5, LVN 5 stated if a resident's (in general) HR was below 60, LVN 5 would notify the RNS on duty and notify the resident's PP (in general). The telephone call with LVN 5 got disconnected.
During an attempted telephone interview on 2/8/2024 at 7:25 pm with LVN 5, LVN 5 stated LVN 5 did not want to answer any more questions during non-working hours.
During an interview on 2/8/2024 at 7:34 pm with the Director of Nursing (DON), the DON stated the licensed nurses (LVN 5, LVN 6, LVN 7, and LVN 8) needed to notify MD 1 when Resident 1's HR was below 60 BPM. The DON stated the licensed nurses (LVN 5, LVN 6, LVN 7, and LVN 8) needed to notify MD 1 when the licensed nurses (LVN 5, LVN 6, LVN 7, and LVN 8) held Resident 1's amiodarone and labetalol for two consecutive days. The DON stated Resident 1's HR below 60 BPM was not within normal limits. The DON stated bradycardia was considered a COC. The DON stated licensed nurses (in general) had to notify the resident's PP when there was a change in resident's condition because the PP, knew the resident's history best. The DON stated licensed nurses (in general) needed to recheck a resident's HR below 60 BPM soon.
During a review of the facility's Policy and Procedure (P&P) titled, Resident Examination and Assessment, revised in 2/2014, the P&P indicated, vital signs were part of the physical exam. The P&P indicated to notify the physician of any abnormalities such as: abnormal vital signs and change in cognitive, behavioral, or neurological behavior status from baseline.
During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised in 5/2017, the P&P indicated, the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status (such as changes in level of care). The P&P indicated, the nurse would notify the resident's attending physician or physician on-call when there has been a significant change in the resident's physical/emotional/mental condition. The P&P indicated, a significant change of condition was a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (that are not self-limiting). The P&P indicated, prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR Communication Form.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep the mouth clean for one of three sampled residen...
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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 keep the mouth clean for one of three sampled residents (Resident 3) by failing to:
Ensure Resident 3 was provided oral care (also known as oral hygiene- the practice of keeping the mouth clean and free of disease and other problems by regular cleaning of teeth, gums, and/or dentures).
This failure had the potential for Resident 3 to develop an infection and put Resident 3 at risk for a decline in health.
Findings:
During a review of Resident 3 ' s admission Record (AR), the AR indicated, the facility admitted Resident 3 to the facility on [DATE], with diagnoses of dysphagia- oropharyngeal phase (difficulty or discomfort in swallowing), dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), and gastro-esophageal- reflux (GERD- condition in which the stomach contents move up into the esophagus tube [muscular tube] from the throat to the stomach that connects mouth to the stomach).
During a review of Resident 3 ' s Care Plan (CP) titled, Activity of Daily Living (ADL- the tasks of everyday life fundamental to caring for oneself), dated 10/3/2023, the CP indicated, Resident 3 had an ADL deficit in personal hygiene. The CP indicated, Resident 3 would be groomed daily for 90 days. The CP indicated, to assist Resident 3 with ADLs as needed.
During a review of Resident 1 ' s Minimum Data Set (MDS- a standardized resident assessment and care screening tool) dated 11/17/2023, the MDS indicated, Resident 1 had severely impaired cognition (ability to think, remember, and function). The MDS indicated, Resident 1 was dependent (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated, Resident 1 depended on staff for rolling left to right, sitting to lying, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers.
During an observation on 2/8/2024 at 11:10 am, of the inside of Resident 3 ' s mouth, Resident 3 ' s mouth was dirty. Resident 3 was observed to have large amounts of dry, brownish, and yellowish crust on the roof (inside top) of mouth and tongue.
During a concurrent observation and interview on 2/8/2024 at 11:18 am with Licensed Vocation Nurse (LVN) 3, Resident 3 ' s mouth was observed. LVN 3 stated mouth care was part of ADL care. LVN 3 stated Resident 3 ' s mouth was supposed to be cleaned by everyone. LVN 3 stated Certified Nurse Assistants (CNAs) needed to do oral care when providing care to Resident 3 and LVN 3 should have checked to see if oral care was provided to Resident 3. LVN 3 stated oral care did not get documented when completed.
During an interview on 2/8/2024 at 12:52 pm with CNA 1, CNA 1 stated oral care could be provided to residents by any nursing staff. CNA 1 stated oral care was done as needed and with ADL care. CNA 1 stated CNA 1 did not do oral care on Resident 3 on the day of the interview because CNA 1, just forgot about it. CNA 1 stated Resident 3 needed frequent oral care because Resident 3 ' s mouth, got dry. CNA 1 stated, in general, oral care needed to be done after meals.
During an interview on 2/8/2024 at 1:40 pm, with CNA 2, CNA 2 stated oral care needed to be provided to residents in the morning.
During an interview on 2/8/2024 at 7:34 pm with the Director of Nursing (DON), the DON stated oral care needed to be done in the morning and evening, and as needed, for residents. The DON stated the CNA flow sheets (used to indicate how much assistance was needed with each residents ' ADLs) did not indicate if an ADL task was completed but documented how much assistance a resident required for the task.
During a review of the facility ' s policy and procedure (P&P) titled, Mouth Care, revised in 2/2018, the P&P indicated, the purpose was to keep the resident ' s lips and oral tissues moist, to cleanse and freshen the mouth, and to prevent oral infection. The P&P indicated, to thoroughly wipe the roof of the resident ' s mouth, inside of the cheeks, tongue and the teeth with applicator or gauze sponges (oral swab used to clean the mouth) and to change the applicator frequently. The P&P indicated, to rinse the resident ' s mouth by use fresh water on the applicators. The P&P indicated to date and time the mouth care was provided, and the name and title of individual(s) providing the care. The P&P indicated to document all assessment data obtained concerning the resident ' s mouth and for the CNA to report to the licensed nurse to record the data in the medical record.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the care plans for two of three sampled res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the care plans for two of three sampled residents (Residents 1 and 3), as indicated in the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, by failing to:
1. Ensure Resident 1 and Resident 3 had daily body checks to monitor for skin injury (bruising, redness, cuts, scratches), or skin tear (a wound that happens when the layers of skin separate or peel back) while giving care and keep Resident 3's bed dry and wrinkle-free, as indicated on Resident 1's and Resident 3's Care Plan (CP) titled, Risk for Skin Breakdown.
This deficient practice could cause a delay in assessment/identification of new skin injuries or wounds and provision of necessary treatment for Resident 1 and 3 and placed Resident 3 at risk for developing new pressure ulcers (PU- localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure).
2. Ensure Resident 1 was monitored for a change of condition (COC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) and abnormal pulse (HR- heartrate/heart beat)(Normal HR was between 60 beats per minute [BPM] to 100 BPM] and reported to Resident 1's Primary Physician (PP)/Medical Doctor (MD) 1 as indicated on Resident 1's CP titled, Atrial Fibrillation.
As a result, on 12/8/2023, from 9:00 am to 5:30 pm, Resident 1 experienced sustained bradycardia (continued HR below 60 BPM) and Resident 1's HR dropped to as low as 42 BPM. Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1's Intensive Care Unit (ICU- unit in hospital providing intensive care for critically ill or injured residents/patients) on 12/8/2023 at 5:31 pm for further evaluation and treatment.
Cross Reference F580 and F686
Findings:
1. During a review of Resident 3's admission Record (AR), the AR indicated, the facility admitted Resident 3 to the facility on [DATE], with diagnoses of dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), type two diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement).
During a review of Resident 3's CP titled, Risk for Skin Breakdown, dated 10/3/2023, the CP indicated, Resident 3 was at risk for skin breakdown. The CP approaches indicated for staff to perform a daily body check to monitor for skin injury or skin tear while giving care, turn/reposition Resident 3 every two hours, and to keep Resident 3's bed dry and wrinkle-free.
During a review of Resident 3's Body Assessment (BA), dated 10/3/2023, the BA indicated Resident 3 did not have a right or left trochanter PU.
During a review of Resident 3's MDS dated [DATE], the MDS indicated, Resident 3 had severely impaired cognition. The MDS indicated, Resident 3 was dependent with oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated, Resident 3 was dependent on staff for rolling left to right, sitting to lying, and tub/shower transfers. The MDS indicated, Resident 3 was at risk of developing PU. The MDS indicated, Resident 3 had one Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present on some parts of the wound bed) PU that was present on admission.
During an interview on 2/8/2024 at 12:52 pm, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 3 was repositioned every two hours with pillows. CNA 1 stated, in general, CNA 1 checked residents' skin every time CNA 1 changed and showered residents. CNA 1 stated on residents' shower days, CNA 1 completed a body check and documented the findings on the shower sheet and gave the sheet to the charge nurses. CNA 1 stated CNA 1 would report redness, bruising, open areas of skin, and skin tears to the charge nurses.
During an interview on 2/8/2024 at 3:11 pm, with Treatment Nurse (TN) 1, TN 1 stated CNAs would check residents' skin on residents' shower days and reported any redness and skin issues to the treatment nurses (TNs). TN 1 stated, in general, TNs needed to perform a weekly skin sweep (WSW, check the whole body for skin issues), of residents' skin, but the TNs were not performing WSW consistently. TN 1 stated, in general, CNAs monitored residents' skin during care. TN 1 stated TNs checked all residents' skin upon admission. TN 1 stated, in general, TNs only assessed residents' skin daily if there was an identified wound.
During a concurrent observation and interview on 2/8/2024 at 4:30 pm with TN 1, Resident 3's right and left hips and thighs were observed. TN 1 stated Resident 3's right trochanter had redness and excoriation (a loss of the epidermis portion and a portion of the dermis due to an injury), from pressure because Resident 3 had been laying on her right side for too long. TN 1 stated Resident 3 had non-blanchable redness to the left trochanter because, Resident 3 had been laying on her left side for too long. TN 1 stated Resident 3's bedsheets were wrinkly underneath Resident 3. TN 1 stated reddened, non-blanchable skin was the result of pressure-related injury. TN 1 stated, You cannot babysit the CNAs all day and make them reposition the residents. TN 1 stated the wound on Resident 3's right trochanter and redness on Resident 3's left trochanter were newly identified at the time of observation. TN 1 stated TN 1 did not get any report of skin issues from any of Resident 3's CNAs.
2. During a review of Resident 1's AR, the AR indicated, the facility admitted Resident 1 to the facility on [DATE] with diagnoses that included muscle wasting (thinning of muscle mass caused by disuse of the muscles or neurogenic conditions), ventilator dependence (dependent on mechanical life support to sustain daily respiration for any part of the day), and DM2.
During a review of Resident 1's Care Plan (CP) titled, Risk for Skin Breakdown, dated 11/13/2023, the CP indicated, Resident 1 was at risk for skin breakdown. The CP approaches indicated, for staff to perform a daily body check to monitor Resident 1 for skin injury (bruising, redness, cuts, scratches), or skin tear (a wound that happens when the layers of skin separate or peel back) while giving care.
During a review of Resident 1's Body Assessment BA dated 11/13/2023, the BA indicated, Resident 1 did not have a PU.
During a review of Resident 1's Wound Assessment Report (WAR) dated 11/13/2023, the WAR indicated, Resident 1 had moisture-associated-skin-damage (MASD- inflammation or skin erosion caused by prolonged exposure to source of moisture on the coccyx (small bone at the end of the spine also known as the tailbone) and perineal area(between the vaginal opening and anus) extending to the perianal area (surrounding the anus) present upon admission to the facility.
During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool) dated 11/17/2023, the MDS indicated, Resident 1 had severely impaired cognition (ability to think, remember, and function). The MDS indicated, Resident 1 was dependent (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated, Resident 1 depended on staff for rolling left to right, sitting to lying, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. The MDS indicated, Resident 1 was at risk of developing PU. The MDS indicated, Resident 1 did not have one or more unhealed PU. The MDS indicated, Resident 1 had a pressure reducing device for bed and was on a turning/repositioning program.
During a review of Resident 1's WARs, dated 12/6/2023, the WARs indicated, Resident 1 developed sacral MASD, left heel diabetic foot ulcer (DFU, open sore or wound that occurs in approximately 15 percent of people with diabetes, and was commonly located on the bottom of the foot), top inner part of the left foot DFU, left lateral malleolus DFU, and left lateral midfoot DFU on 12/6/2023. The WARs indicated, the wounds were not present on admission and the wounds were newly developed.
During a review of Resident 1's General Acute Care Hospital 1 Wound Care Notes (WCN), dated 12/10/2023, timed at 4:03 pm, the WCN indicated, Resident 1 was admitted to GACH 1 on 12/8/2023 with multiple pressure ulcers present-on-admission. The WCN indicated, Resident 1 had Stage 3 PUs on Resident 1's right and left buttocks and right and left posterior thighs, Unstageable PUs on Resident 1's left lateral ankle and right and left lateral heels, DTI on Resident 1's right and left lateral midfoot and lateral fifth metatarsal head, and full thickness open wound on Resident 1's left dorsal foot.
During an interview on 2/8/2024 at 7:34 pm with the Director of Nursing (DON), the DON stated charge nurses did not complete daily body checks on residents. The DON stated charge nurses were required to complete a head-to-assessment (assessment of all body system used to gather patient data and determine a patient's health status) weekly and document the assessment on the Nursing (Weekly) Summaries. The DON stated treatment nurses needed to complete a weekly pressure ulcer risk assessment and the weekly wound assessment. The DON stated CNAs were supposed to check residents' skin during showers and activity of daily living (ADL- the tasks of everyday life fundamental to caring for oneself) care. The DON stated CNAs were supposed to look for bumps, skin tears, bruises (mark on the skin caused by blood trapped under the surface because of injury to small blood vessels but does not break the skin), scratches (damage to the surface of skin cause by something sharp or rough), breakdown, excoriation, redness. The DON stated part of the facility's PU prevention protocol was to look at incontinence (lack of control over urination or defecation) care, care planning, and repositioning. The DON stated residents MASD should not get worse if staff were monitoring residents' skin every day, and CNAs were turning and repositioning residents as indicated, and changing residents so they do not remain wet in soiled briefs. The DON stated staff needed to keep residents with MASD clean and dry and check them at least every two hours.
3. During a review of Resident 1's admission Assessment (AA) dated 11/13/2023 at 7 pm, the AA indicated Resident 1 had an irregular pulse rhythm (abnormal heartbeat).
During a review of Resident 1's Care Plan (CP) titled, Atrial Fibrillation, dated 11/13/2023, the CP indicated, Resident 1 was at risk for irregular pulse/irregular heartbeat, chest pain, and shortness of breath (SOB) due to A-fib. The CP indicated, for staff to monitor Resident 1 for chest pain or abnormal HR and report to the physician.
During a review of Resident 1's Physician Orders (PO), dated 11/13/2023, the PO indicated to administer amiodarone hydrochloride (HCL) 100 milligrams (mg- unit of measurement) tablet, give one (1) tablet by gastrostomy tube (GT- tube inserted through the stomach to deliver nutrition and/or medication) every 12 hours for A-fib and hold (do not give) amiodarone for a HR less than (<) 60 BPM.
During a review of Resident 1's PO, dated 11/17/2023, the PO indicated to administer labetalol HCL 100 mg tablet, give 1 tablet by GT every 12 hours at 9 am and 9 pm for hypertension, and hold labetalol for systolic blood pressure (SBP- top number of the blood pressure reading; pressure in the arteries when the heart beats) of 110 millimeters of mercury (mmHg, unit of measurement) or HR < 60 BPM.
During a review of Resident 1's Medication Administration Record (MAR- a report that serves as a legal record of the medications administered to a resident) for December 2023, the MAR indicated the following:
1. LVN 6 held the amiodarone and labetalol on 12/3/2024 at 9 pm for HR of 56 BPM.
2. LVN 7 held the amiodarone and labetalol on 12/4/2024 at 9 am for HR of 59 BPM.
3. LVN 6 held the amiodarone and labetalol on 12/4/2024 at 9 pm for HR of 58 BPM.
4. LVN 7 held the amiodarone and labetalol on 12/5/2024 at 9 am for HR of 58 BPM.
5. LVN 8 held the amiodarone and labetalol on 12/7/2024 at 9 am for HR of 58 BPM.
6. LVN 5 held the amiodarone and labetalol on 12/8/2024 at 9 am for HR of 50 BPM.
During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations), dated 12/8/2023, timed at 3:24 pm, the SBAR indicated, Resident 1's HR was 46 BPM. The SBAR indicated, Resident 1's blood pressure (BP- the pressure circulating blood against the walls of blood vessels; abnormal BP was less than 120/80 mmHg and above140/90 mmHg was considered high blood pressure) was 149/90 mmHg. The SBAR indicated, Resident 1 appeared comatose (state of deep unconsciousness for a prolonged or indefinite period because of severe illness or injury). The SBAR indicated, LVN 5 notified Resident 1's nephrologist (MD 2) on 12/8/2023 at 3:24 pm regarding Resident 1 had a HR of 46 BPM.
During a review of Resident 1's Departmental Notes (DN), dated 12/8/2023, timed at 7:33 pm, the DN indicated, (on 12/8/2023) at 3:30 pm, MD 2 evaluated/assessed Resident 1. The DN indicated, Resident 1's BP was 168/91 mmHg and HR was 46 BPM. The DN indicated, MD 2 ordered to transfer Resident 1 to GACH 1 for further evaluation and treatment if Resident 1 sustained a low HR. The DN indicated, (on 12/8/2023) at 5:01 pm, Resident 1's HR was 42 BPM. Registered Nurse Supervisor (RNS) 1 notified MD 2 and MD 2 ordered to transfer Resident 1 to GACH 1. The DN indicated, RNS 1 called 911 (emergency medical services) and paramedics (healthcare professional trained to give emergency medical care to people who are injured or ill outside of a hospital) arrived at the facility at 5:07 pm. The DN indicated, Resident 1 left the facility at 5:20 pm.
During an interview on 2/8/2024 at 10:39 am with LVN 3, LVN 3 stated abnormal vital signs (VS- measurements of the body's most basic functions consisting of body temperature, pulse [HR], respiratory [breathing] rate, blood pressure, and oxygen levels) were considered as COC. LVN 3 stated when a resident (in general) had a COC, LVN 3 would complete a SBAR and notify the resident's physician (in general) and report all findings promptly.
During an interview on 2/8/2024 at 12:52 pm, with Certified Nurse Assistant (CNA) 1, CNA 1 stated a resident being not as responsive was considered a COC. CNA 1 stated CNA 1 would report a COC to the charge nurse.
During a concurrent telephone interview and record review on 2/8/2024 at 6:45 pm with MD 1, Resident 1's MAR for the month of December 2024 and the SBAR dated 12/8/2023 were reviewed. MD 1 stated MD 1 was Resident 1's PP; However, LVN 5, 6, 7, and 8 did not notify MD 1 of Resident 1's HR below 60 BPM and when the LVNs (LVN 5, 6, 7, and 8) held amiodarone and labetalol to Resident 1 due to Resident 1's HR was below 60 BPM (on 12/3/2024 at 9 pm, 12/4/2024 at 9 am and 9 pm, 12/5/2024 at 9 am, 12/7/2024 at 9 am, and 12/8/2024 at 9 am). MD 1 stated LVN 5 did not notify MD 1 of Resident 1's change of condition on 12/8/2023 at 3:24 pm. MD 1 stated LVN 5 notified MD 2. MD 1 stated a facility staff (unidentified) notified MD 1 of Resident 1's COC when Resident 1 was transferred to GACH 1 via 911 (on 12/8/2023 at around 5:20 pm). MD 1 stated MD 2 is a nephrologist and MD 2 first saw Resident 1 at the facility on 12/8/2023. MD 1 stated if the facility had notified MD 1 of Resident 1's bradycardia, MD 1 would have ordered to transfer Resident 1 to GACH 1 right away due to Resident 1's comorbidities (more than one disease/condition is present in a person at the same time and associated with worse health outcomes and more complex clinical management).
During a telephone interview on 2/8/2024 at 7:16 pm with LVN 5, LVN 5 stated if a resident's (in general) HR was below 60, LVN 5 would notify the RNS on duty and notify the resident's PP (in general).
During an interview on 2/8/2024 at 7:34 pm, with the Director of Nursing (DON), the DON stated the licensed nurses needed to notify MD 1 when Resident 1's HR was below 60 BPM. The DON stated the licensed nurses needed to notify MD 1 when the licensed nurses held Resident 1's amiodarone and labetalol for two consecutive days. The DON stated Resident 1's HR below 60 BPM was not within normal limits. The DON stated bradycardia was considered a COC. The DON stated licensed nurses (in general) had to notify the resident's PP when there was a change in resident's condition because the PP, knew the resident's history best. The DON stated licensed nurses (in general) needed to recheck a resident's HR below 60 BPM soon. The DON acknowledged that the facility failed to implement Resident 1's care plan.
During a review of the facility's P&P titled, Care Plans, Comprehensive, Person-Centered, revised in 12/2016, the P&P indicated, a comprehensive, person-centered CP that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs would be developed and implemented for each resident. The P&P indicated, CP interventions (approaches/plan) were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The P&P indicated the CP will include services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial (mental, emotional, social, and spiritual effects) well-being.
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 observation, interview, and record review, the facility failed to provide care and services for two of three sampled re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services for two of three sampled residents (Residents 1 and 3), who were assessed as being high risk for developing pressure ulcers (PU- localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear [mechanical force that cause the skin to break off] and/or friction [movement of one surface of the skin against the others]), to prevent the development of new PU) by failing to:
1. Ensure facility staff accurately assessed and monitored Resident 1's and Resident 3's skin condition.
2. Ensure Treatment Nurse (TN) 1, TN 2, TN 3, and TN 4 assessed and documented Residents 1's and 3's risk for developing a pressure ulcer weekly as indicated in the facility's policies and procedures (P&P) titled, Prevention of Pressure Injuries (PU), and Pressure Injury Risk Assessment.
As a result, Resident 1's pressure ulcers of different stages (to determine extent of damage of the pressure ulcer) on multiple body sites were not properly assessed and treated at the facility. Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 12/8/2023 at 5:31 pm with multiple pressure ulcers not previously assessed by the facility. Resident 3 developed Stage 2 (wound that is open and involving the top-most skin layers) PU on the right trochanter (bony prominence on the outer, upper part of the thigh bone [femur]) and Stage 1 (wound not open and reddened and was not blanchable [occurred when redness or discoloration disappeared with pressures but then returned because blood was still inside the vessels being moved around]) PU on the left trochanter that were not previously assessed by the facility.
Cross Reference: F656
Findings:
1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on [DATE] with diagnoses that included muscle wasting (thinning of muscle mass caused by disuse of the muscles or neurogenic conditions), ventilator dependence (dependent on mechanical life support to sustain daily respiration for any part of the day), and type 2 diabetes mellitus (DM 2, a long-term condition in which the body has trouble controlling blood sugar and using it for energy).
During a review of Resident 1's Care Plan (CP) titled, Risk for Skin Breakdown, dated 11/13/2023, the CP indicated, Resident 1 was at risk for skin breakdown. The CP approaches indicated for staff to perform a daily body check to monitor Resident 1 for skin injury (bruising, redness, cuts, scratches), or skin tear (a wound that happens when the layers of skin separate or peel back) while giving care.
During a review of Resident 1's Body Assessment (BA) on admission dated 11/13/2023, the BA indicated, Resident 1 had a moisture-associated-skin-damage (MASD- inflammation or skin erosion caused by prolonged exposure to source of moisture) on the coccyx (small bone at the end of the spine also known as the tailbone) and perineal area (between the vaginal opening and anus) extending to the perianal area (surrounding the anus). The BA indicated, Resident 1 did not have any PU.
During a review of Resident 1's Wound Assessment Report (WAR) dated 11/13/2023, the WAR indicated Resident 1 had MASD on the coccyx and perineal area extending to the perianal area present upon admission to the facility.
During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool) dated 11/17/2023, the MDS indicated, Resident 1 had severely impaired cognition (ability to think, remember, and function). The MDS indicated, Resident 1 was dependent (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated, Resident 1 depended on staff for rolling left to right, sitting to lying, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. The MDS indicated, Resident 1 was at risk of developing PU. The MDS indicated, Resident 1 did not have one or more unhealed PU. The MDS indicated, Resident 1 had a pressure reducing device for bed and was on a turning/repositioning program.
During a review of Resident 1's Nursing (Weekly) Summaries (NS) dated 11/23/2023, 12/1/2023, 12/7/2023, the NS indicated, Resident 1 had existing wound/skin conditions. The NS indicated, no documentation of Resident 1's specific existing wound/skin conditions or locations.
During a review of Resident 1's Braden Risk Assessment Report ([NAME], a standardized assessment tool used to assess and document a patient's risk for developing pressure ulcers) dated 12/6/2023, the [NAME] indicated, Resident 1 was at very high risk for developing PU. The [NAME] indicated, TN 3 completed the [NAME] due to a change in Resident 3's condition (COC- a change in resident's health or functioning that requires further assessment and intervention).
During a review of Resident 1's WAR, dated 12/6/2023, the WAR indicated Resident 1 had a diabetic foot ulcer (DFU- open sore or wound that occurs in approximately 15 percent of people with diabetes, and is commonly located on the bottom of the foot) on Resident 1's left lateral (to the side or away from the middle of the body) midfoot which measured three (3) centimeters (cm, unit of measurement)in length, two (2) cm in width and unable to determine (UTD) depth. The WAR indicated, Resident 1's DFU was not present on admission and was new.
During a review of Resident 1's WAR dated 12/6/2023, the WAR indicated, Resident 1 had a DFU on Resident 1's left lateral malleolus which measured 2 cm by 2 cm. The WAR indicated, the wound was not present on admission and was new.
During a review of Resident 1's WAR dated 12/6/2023, the WAR indicated, Resident 1 had a DFU on the left heel which measured 2 cm by 2 cm. The WAR indicated, the wound was not present on admission and was new.
During a review of Resident 1's WAR dated 12/6/2023, the WAR indicated, Resident 1 had a DFU on the top inner part of Resident 1's left foot which measured 3 cm by 2 cm. The WAR indicated, the wound was not present on admission and was new.
During a review of Resident 1's WAR dated 12/6/2023, the WAR indicated, Resident 1 had a MASD on the sacrum (portion of the spine between the lower back and tailbone). The WAR indicated, the MASD was not present on admission and was new.
During a review of Resident 1's General Acute Care Hospital (GACH) 1 Wound Care Notes (WCN), dated 12/10/2023, timed at 4:03 pm, the WCN indicated, Resident 1 was admitted to GACH 1 on 12/8/2023 with multiple pressure ulcers present-on-admission. The WCN indicated, Resident 1 had Stage 3 PU on Resident 1's right and left buttocks and right and left posterior thighs, Unstageable PU on Resident 1's left lateral ankle and right and left lateral heels, DTI on Resident 1's right and left lateral midfoot and lateral fifth metatarsal head, and full thickness open wound on Resident 1's left dorsal foot.
2. During a review of Resident 3's AR, the AR indicated, the facility admitted Resident 3 to the facility on [DATE], with diagnoses that included protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), and DM 2.
During a review of Resident 3's CP titled, Risk for Skin Breakdown, dated 10/3/2023, the CP indicated, Resident 3 was at risk for skin breakdown. The CP approaches indicated, for staff to perform a daily body check to monitor for skin injury or skin tear while giving care and to turn/reposition Resident 3 at least every two hours.
During a review of Resident 3's BA on admission, dated 10/3/2023, the BA indicated Resident 3 did not have a right or left trochanter PU.
During a review of Resident 3's [NAME] dated 10/3/2023, the [NAME] indicated, Resident 3 was at high risk for developing a PU. The [NAME] indicated, LVN 2 completed the assessment for Resident 3's admission.
During a review of Resident 3's NS dated 10/10/2023, 10/17/2023, 10/24/2023, 11/7/2023, 11/14/2023, 11/21/2023, 11/28/2023, 12/6/2023, 12/12/2023, 12/19/2023, 12/26/2023, 1/2/2024, 1/9/2024, 1/17/2024, 1/24/2024, 1/31/2024, and 2/7/2024, the NS indicated, Resident 3 had existing wound/PU/skin conditions. The NS indicated, no documentation of Resident 3's specific existing wound/skin conditions or locations.
During a review of Resident 3's MDS dated [DATE], the MDS indicated, Resident 3 had severely impaired cognition. The MDS indicated, Resident 3 was dependent with oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated, Resident 3 was dependent on staff for rolling left to right, sitting to lying, and tub/shower transfers. The MDS indicated, Resident 3 was at risk of developing PU. The MDS indicated, Resident 3 had one Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present on some parts of the wound bed) PU that was present on admission.
During an interview on 2/8/2024 at 12:52 pm, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 3 was repositioned every two hours with pillows. CNA 1 stated, in general, CNA 1 checked residents' skin every time CNA 1 changed and showered residents. CNA 1 stated on residents' shower days, CNA 1 completed a body check and documented the findings on the shower sheet and gave the sheet to the charge nurses. CNA 1 stated CNA 1 would report redness, bruising, open areas of skin, and skin tears to the charge nurses.
During an interview on 2/8/2024 at 3:11 pm with Treatment Nurse (TN) 1, TN 1 stated if a resident had a diagnosis of DM 2 and had a wound on the lower extremity (leg), the wound would be assessed as a diabetic ulcer. TN 1 stated a diabetic ulcer could be caused by pressure. TN 1 stated if a resident who did not have DM 2 developed a wound on the lower extremity, the wound would be assessed as a PU or DTI.
During a concurrent interview and record review on 2/8/2024 at 3:11 pm with TN 1, Resident 3's medical record was reviewed. TN 1 stated CNAs would check residents' skin on residents' shower days and reported any redness and skin issues to the TNs. TN 1 stated TNs needed to perform a weekly skin sweep (WSW, checking the patient's whole body for skin issues) of residents' skin and complete a weekly pressure ulcer risk assessment for residents with wounds. TN 1 stated the facility used the Braden Risk Assessment Report form to document the weekly pressure ulcer risk assessment. TN 1 stated Resident 3's medical record did not have weekly pressure ulcer risk assessment. TN 1 stated TNs were not performing WSW and completing the weekly pressure ulcer risk assessment consistently. TN 1 stated, in general, CNAs were the ones who monitored residents' skin during care. TN 1 stated TNs checked all residents' skin upon admission. TN 1 stated, in general, TNs only assessed residents' skin daily if there was an identified wound.
During a concurrent interview and record review on 2/8/2024 at 3:11 pm with TN 1, Resident 3's medical record was reviewed. TN 1 stated TNs needed to complete the weekly skin assessments and weekly pressure ulcer risk assessments for residents with wounds.
During a concurrent observation and interview on 2/8/2024 at 4:30 pm with TN 1, Resident 3's right and left hips and thighs were observed. TN 1 stated Resident 3's right trochanter had redness and excoriation (a loss of the epidermis portion and a portion of the dermis due to an injury), from pressure because Resident 3 had been laying on her right side for too long. TN 1 stated Resident 3 had non-blanchable redness to the left trochanter because, Resident 3 had been laying on her left side for too long. TN 1 stated Resident 3's bedsheets were wrinkly underneath Resident 3. TN 1 stated reddened, non-blanchable skin was the result of pressure-related injury. TN 1 stated, You cannot babysit the CNAs all day and make them reposition the residents. TN 1 stated the wound on Resident 3's right trochanter and redness on Resident 3's left trochanter were newly identified at the time of observation. TN 1 stated TN 1 did not get any report of skin issues from any of Resident 3's CNAs.
During a concurrent interview and record review on 2/8/2024 at 5:43 pm with Licensed Vocational Nurse (LVN) 1, Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations) dated 12/6/2023 at 3:48 pm and WAR dated 12/6/2023 were reviewed. LVN 1 stated TN 3 (who no longer worked at facility), documented on the SBAR that a CNA (unidentified) called TN 3 into Resident 1's room and TN 3 found redness to Resident 1's buttocks and several diabetic ulcers to Resident 1's left foot. LVN 1 stated Resident 1 developed sacral MASD, left heel DFU, top of left foot DFU, left lateral malleolus DFU, and left lateral midfoot DFU on 12/6/2023.
During an interview on 2/8/2024 at 7:34 pm with the Director of Nursing (DON), the DON stated charge nurses did not complete daily body checks on residents. The DON stated charge nurses were required to complete a head-to-assessment (assessment of all body system used to gather patient data and determine a patient's health status) weekly and document the assessment on the Nursing (Weekly) Summaries. The DON stated treatment nurses needed to complete a weekly pressure ulcer risk assessment and the weekly wound assessment. The DON stated CNAs were supposed to check residents' skin during showers and activity of daily living (ADL- the tasks of everyday life fundamental to caring for oneself) care. The DON stated CNAs were supposed to look for bumps, skin tears, bruises (mark on the skin caused by blood trapped under the surface because of injury to small blood vessels but does not break the skin), scratches (damage to the surface of skin cause by something sharp or rough), breakdown, excoriation, redness. The DON stated part of the facility's PU prevention protocol was to look at incontinence (lack of control over urination or defecation) care, care planning, and repositioning. The DON stated residents MASD should not get worse if staff were monitoring residents' skin every day, and CNAs were turning and repositioning residents as indicated, and changing residents so they do not remain wet in soiled briefs. The DON stated staff needed to keep residents with MASD clean and dry and check them at least every two hours. The DON stated turning and repositioning, and incontinence care were the standards of practice for PU prevention and for preventing MASD from turning into a PU. The DON stated if a resident's feet were under the sheets, a PU could develop within eight hours.
During a review of the P&P titled, Prevention of Pressure Injuries (PU), revised in 4/2020, the PP indicated the purpose was to provide information regarding identification of PU risk factors and interventions for specific risk factors. The PP indicated to review the resident's care plan and identify the risk factors as well as interventions designed to reduce or eliminate those considered modifiable. The PP indicated to assess a resident on admission for existing pressure injury risk factors. The PP indicated to repeat the risk assessment weekly and upon any changes in condition. The PP indicated to conduct a comprehensive skin assessment upon admission, with each risk assessment, as indicated, according to the resident's risk factors, and prior to discharge. The PP indicated to inspect skin daily when performing or assisting with personal care or ADLs. The PP indicated to identify signs of developing PU (such as non-blanchable erythema (redness of skin caused by injury). The PP indicated to inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium and trochanter). The PP indicated to monitor regularly for comfort and signs of pressure-related injury. The PP indicated to evaluate, report, and document potential changes in the skin. The PP indicated to review the interventions and strategies for effectiveness on an ongoing basis.
During a review of facility's P&P titled, Pressure Injury Risk Assessment, revised in 3/2020, the P&P indicated the purpose was to provide guidelines for structured assessment and identification of residents at risk for developing new PU or worsening of existing PU. The PP indicated to conduct the risk assessment as soon as possible after admission. The PP indicated to repeat the risk assessment weekly for the first four weeks, for a signification COC, or as often as was required based on the resident's condition. The PP indicated to conduct a comprehensive skin assessment with every risk assessment. The PP indicated to document the type of assessment(s) conducted. The PP indicated to document the condition of the resident's skin (such as size and location of any red or tender areas), if identified.
Jan 2024
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a plan of care to address the Stage 3 pressur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a plan of care to address the Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present) on the left clavicle (collar bone) of one of seven sampled residents (Resident 3) in accordance with the facility ' s policy and procedure (PP) titled, Care Plans, Comprehensive Person-Centered.
As a result of this failure, Resident 3 went five days without care and treatment for Resident 3 ' s pressure ulcer on the left clavicle which had the potential to worsen Resident 3's pressure ulcer and/or cause infection.
Cross Reference F686
Findings:
During a review of Resident 3 ' s Face Sheet (admission Record- AR), the AR indicated the facility initially admitted Resident 3 on 10/27/2023 and readmitted the resident on 1/17/2024, with diagnoses of anoxic brain injury (stopping of blood flow into and within the brain due to injury), dependence on ventilator (the need for mechanical ventilation in order to breathe), and unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [non-viable yellow, tan, gray, green or brown tissue consists of dead cells] or eschar [dead tissue]) of other site (site not specified).
During a review of Resident 3 ' s Braden Risk Assessment Report (BRAB- assessment tool used to assess a resident ' s risk of developing a pressure ulcer), dated 10/28/2023, the BRAB indicated Resident 3 was at very high risk for developing a pressure ulcer.
During a review of Resident 3 ' s Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 11/2/2023, the MDS indicated Resident 3 had severely impaired cognition (ability to think, remember and function). The MDS indicated Resident 3 was dependent (helper does all of the effort) on the staff for oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, and personal hygiene). The MDS indicated Resident 3 was at risk for developing pressure ulcers and had two unstageable pressure ulcers present upon admission to the facility.
During a review of Resident 3 ' s Wound Assessment Report (WAR), dated 12/28/2023, the WAR indicated Resident 3 had Moisture Associated Skin Damage (MASD- inflammation or skin erosion caused by prolonged exposure to source of moisture) on the left clavicle, extending to the neck area. The WAR indicated the left clavicular wound was identified on 10/28/2023 and was present upon admission. The WAR indicated the assessment on 12/28/2023 was a weekly update.
During a review of Resident 3 ' s Situation-Background-Assessment-Recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations), dated 1/4/2024 at 6:21 am, the SBAR indicated Resident 3 had a temperature of 102.3 degrees Fahrenheit (F- unit of measurement). The SBAR indicated Resident 3 was sent to General Acute Care Hospital 1 (GACH 1) for further evaluation.
During a review of Resident 3 ' s GACH 1 Progress Notes, dated 1/16/2024, the Progress Notes indicated Resident 3 had a left upper, anterior (front) chest pressure injury (ulcer), present upon admission to GACH 1 on 1/4/2024.
During a concurrent interview and record review on 1/22/2024 at 2:30 pm with MDS Nurse (MDSN) 1, Resident 3 ' s physician orders and body assessment from 1/17/2024 were reviewed. MDSN 1 stated Resident 3 had no current orders to treat a left clavicle wound. MDSN 1 stated Resident 3 ' s body assessment indicated no wound to the left clavicle extending to the neck when the facility readmitted Resident 3 from GACH 1 on 1/17/2024.
During an interview on 1/22/2024 at 2:51 pm with Licensed Vocational Nurse (LVN) 6, LVN 6 stated LVN 6 did not treat a left clavicle wound during Resident 3 ' s treatment on the day of the interview. LVN 6 stated there were no physician orders to treat Resident 3 ' s left clavicle wound.
During an interview on 1/22/2024 at 3:21 pm with LVN 13, LVN 13 stated Resident 3 ' s readmission skin assessment (on 1/17/2024) was not done by a treatment nurse. LVN 13 stated Resident 3 ' s left clavicle wound was not assessed by the admitting nurse on 1/17/2024. LVN 13 stated there was no care plan developed for Resident 3 ' s left clavicle wound.
During an interview on 1/22/2024 at 3:26 pm with LVN 6, LVN 6 stated LVN 6 did not notice a wound on Resident 3 ' s left clavicle when LVN 6 treated Resident 3 ' s other wounds the morning of the interview.
During a concurrent observation and interview on 1/22/2024 at 3:37 pm with LVN 13, Resident 6 ' s left clavicle was observed. LVN 13 stated Resident 3 had a Stage 3 pressure ulcer on the left clavicle. LVN 13 stated there was 30 percent (%) slough and 70% granulation tissue (type of new connective tissue that protects wound surfaces microbes and further injury). LVN 13 stated Resident 3 ' s left clavicle pressure ulcer was over the bony prominence and measured 1.9 centimeters (cm- unit of measurement) length by 0.5 cm width, and 0.1 cm deep. LVN 13 stated Resident 3 ' s left clavicle wound was not assessed or treated since Resident 3 was readmitted to the facility on [DATE].
During an interview on 1/22/2024 at 4:57 pm with LVN 16, LVN 16 stated LVN 16 worked on 1/18/2024 as a treatment nurse. LVN 16 stated LVN 16 was not aware Resident 3 was readmitted to the facility. LVN 16 stated LVN 16 did not perform Resident 3 ' s admission skin assessment (on 1/17/2024). LVN 16 stated Resident 3 ' s medical record had other orders, so LVN 16 assumed another staff performed Resident 3 ' s admission skin assessment. LVN 16 stated not performing Resident 3 ' s admission skin assessment could worsen Resident 3 ' s left clavicle wound because it was not treated since Resident 3 ' s readmission on [DATE].
During an interview on 1/24/2024 at 4:34 pm with the Director of Nursing (DON), the DON stated in general, charge nurses and treatment nurses were supposed to perform admission skin assessments on all residents. The DON stated if a resident went to the hospital and was readmitted , the admitting nurse was supposed to perform a skin assessment and the treatment nurse was supposed to do a reassessment to ensure no wounds or potential for wounds were missed. The DON stated if skin assessments were not being performed accurately, the resident ' s skin conditions would not be reflected accurately. The DON stated accurate skin assessments were important so a plan of care could be developed and implemented. The DON stated if there was no care plan to address the resident ' s pressure ulcer or skin condition then staff would not know how to assess, monitor, and treat the resident ' s pressure ulcer.
During a review of the facility ' s PP titled Care Plans, Comprehensive Person-Centered, revised 12/2016, the PP indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will include measurable objectives and timeframes and describe the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. The PP indicated identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.
During a review of the facility ' s policy and procedure (PP) titled, Prevention of Pressure Injuries, revised 4/2020, the PP indicated the purpose of the PP was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The PP indicated a risk assessment was to be performed within eight hours of admission for existing pressure injury risk factors. The PP indicated to conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, and indicated according to the resident ' s risk factors, and prior to discharge. The PP indicated to inspect the skin on a daily basis while performing or assisting with personal care or activities of daily living. The PP indicated to identify any signs of developing pressure injuries, and for darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency. The PP indicated to inspect pressure points (bony prominences). The PP indicated to evaluate, report and document potential changes in the skin. The PP indicated to review the interventions and strategies for effectiveness on an ongoing basis.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) titled, Care...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) titled, Care of Fingernails/Toenails, for two of three sampled residents (Resident 9 and Resident 10) who were on dialysis (a procedure where a machine cleans the blood because the kidneys can no longer clean the blood) by failing to:
1. Ensure Resident 9 ' s and Resident 10 ' s fingernails were cleaned daily and kept trimmed.
2. Provide Resident 9 and Resident 10 assistance with personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, nail care, washing/drying face, and hands) as indicated by Resident 9 ' s and Resident 10 ' s activities of daily living (ADLs) care plan.
3. Ensure provision of nail care was documented in Resident 9 ' s and Resident 10 ' s medical record according to the facility ' s P&P.
These failures had the potential for Resident 9 and Resident 10 to sustain skin injuries from scratching and to develop an infection.
Findings:
1. During a review of Resident 9 ' s Face Sheet or admission Record (AR), the AR indicated the facility admitted Resident 9 on 10/26/2023 with diagnoses which included end stage renal disease (ESRD, when the kidneys can no longer clean the blood). The AR indicated Resident 9 was dependent on dialysis.
During a review of Resident 9 ' s ADL care plan, dated 10/26/2023, the ADL care plan indicated Resident 9 required extensive assistance with personal hygiene. The ADL care plan indicated to monitor Resident 9 for ADLs needs and to assist Resident 9 with ADLs as needed.
During a review of Resident 9 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/1/2023, the MDS indicated Resident 9 ' s cognitive (ability to think and reason) status was intact and Resident 9 required moderate assistance with personal hygiene.
During a review Resident 9 ' s CNA Flow Sheet, dated 1/2024, the CNA Flow Sheet indicated there was no documented evidence nail care was provided to Resident 9.
2. During a review of Resident 10 ' s admission Record, the AR indicated the facility admitted Resident 10 on 12/15/17 and readmitted Resident 10 on 5/26/2023 with diagnoses which included end stage renal disease. The AR indicated Resident 10 was dependent on dialysis.
During a review of Resident 10 ' s ADL care plan, dated 12/14/2022, the ADL care plan indicated Resident 10 was dependent on staff to maintain personal hygiene. The ADL care plan indicated to monitor Resident 10 for ADLs needs and to assist Resident 10 with ADLs as needed.
During a review of Resident 10 ' s MDS, dated [DATE], the MDS indicated Resident 10 was nonverbal and did not express Resident 10 ' s ideas and needs. The MDS indicated Resident 10 was dependent on staff to maintain personal hygiene.
During a review Resident 10 ' s CNA Flow Sheet, dated 1/2024, the CNA Flow Sheet indicated there was no documented evidence nail care was provided to Resident 10.
During an interview on 1/22/2024 at 1:41 pm with Licensed Vocational Nurse 16 (LVN 16), LVN 16 stated all nursing staff (RNs, LVNS, CNAs) monitored residents ' nails every time nursing staff provided care to residents. LVN 16 stated all nursing staff trimmed and cleaned residents ' nails.
During a concurrent observation and interview on 1/22/2024 at 1:53 pm with Resident 9 in Resident 9 ' s room, Resident 9 ' s fingernails were long and dirty. Resident 9 stated Resident 9 did not know who and how often Resident 9 ' s nails were trimmed and cleaned.
During a concurrent observation and interview on 1/22/2024 at 1:58 pm with LVN 16 in Resident 9 ' s room, Resident 9 was observed scratching Resident 9 ' s right chest where Resident 9 ' s dialysis access line was. LVN 16 pulled down Resident 9 ' s gown to check on Resident 9 ' s dialysis access line and noted there was no dressing that covered the dialysis access line site. LVN 16 stated Resident 9 occasionally removed Resident 9 ' s dialysis access line site dressing. LVN 16 noted Resident 9 ' s fingernails were long and dirty. LVN 16 stated Resident 9 ' s fingernails could use a little cleaning and cutting. LVN 16 stated nursing staff trimmed and cleaned residents ' nails every week.
During a concurrent observation and interview on 1/22/2024 at 2:11 pm with Registered Nurse Supervisor 3 (RN 3) in Resident 9 ' s room, RN 3 noted Resident 9 ' s fingernails were long and dirty. RN 3 stated it was important for residents who were on dialysis to have clean and short nails because residents could scratch and touch their dialysis access line and their dirty nails could become a source of infection.
During an interview on 1/22/2024 at 2:26 pm with Certified Nursing Assistant 16 (CNA 16), CNA 16 stated CNAs trimmed and cleaned residents ' nails every Sunday. CNA 16 stated CNA 16 checked residents ' nails every time CNA 16 provided care to residents. CNA 16 stated CNA 16 would offer to trim and clean residents ' nails, but residents sometimes refused. CNA 16 stated CNA 16 showered and offered to cut and clean Resident 9 ' s nails earlier that day but Resident 9 refused. CNA 16 stated it was important for residents to have clean and short nails to prevent scratches, skin tears, and infection.
During a concurrent observation and interview on 1/23/2024 at 12:35 pm with LVN 18 in Resident 10 ' s room, Resident 10 was noted to have a dialysis access line on Resident 10 ' s left thigh. LVN 18 noted Resident 10 ' s fingernails were long and dirty. LVN 18 stated all licensed nurses and CNAs were supposed to check the residents ' nails every time licensed nurses and CNAs provided care to residents. LVN 18 stated licensed nurses and CNAs should trim and clean residents ' nails, as soon as licensed nurses and CNAs noted residents ' nails were long and dirty. LVN 18 stated it was important for residents to have clean and short nails to prevent residents from scratching and to prevent infection.
During an interview on 1/23/2024 at 12:43 pm with CNA 17, CNA 17 stated CNAs needed to cut and clean residents ' nails as soon as CNAs noted the residents ' nails were long and dirty. CNA 17 stated CNA 17 noted Resident 10 ' s nails were long and dirty when CNA 17 cleaned Resident 10 ' s hands earlier that day and planned to cut and clean Resident 10 ' s nails later that day. CNA 17 stated CNAs checked residents ' nails every time CNAs provided care to residents. CNA 17 stated CNAs did not provide resident showers on Thursdays because CNAs were supposed to only shave residents and provide nail care on Thursdays.
During an interview on 1/23/2024 at 12:57 pm with CNA 18, CNA 18 stated nail care was done as needed when resident ' s nails were long and dirty, but CNAs checked residents ' nails every day when CNAs provided care. CNA 18 stated CNAs did not provide resident showers on Thursdays because CNAs were supposed to only shave residents, do nail care, and clean and organize residents ' closets every Thursday.
During an interview on 1/23/2024 at 2:34 pm with Minimum Data Set Nurse 1 (MDSN 1), MDSN 1 reviewed Resident 9 ' s and Resident 10 ' s medical records. MDSN 1 stated nail care was not documented in the CNA Flow Sheet or in the progress notes.
During an interview on 1/23/2024 at 3:48 pm with the Director of Staff Development (DSD), the DSD stated nursing staff were supposed to do nail care as soon as nursing staff noticed the resident ' s nails to be long and dirty. The DSD stated nail care was part of ADL and personal hygiene and CNAs were supposed to check residents ' nails every time they provided ADL care. The DSD stated there was one day a week in the facility when CNAs did not provide resident showers so that CNAs could provide nail care. The DSD stated nail care was provided on Thursdays, but one Station (patient care area where residents reside in the facility) provided nail care on Sundays. The DSD stated it was important for residents to have clean and short nails to prevent from getting injured and because residents sometimes put their fingers in their mouths and used their hands to eat.
During an interview on 1/24/2024 at 1:08 pm with the Director of Nursing (DON), the DON stated CNAs needed to look at residents ' nails when CNAs provided residents daily care every shift. The DON stated residents ' nails needed to be clean and trimmed to prevent scratches and infection.
During a review of the facility ' s P&P titled, Care of Fingernails/Toenails, dated February 2018, the P&P indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The P&P indicated to review the resident ' s care plan prior to providing nail care, and to provide daily cleaning and regular trimming as part of nail care. The P&P indicated, the following information should be recorded in the resident ' s medical record:
1. The date and time that nail care was given.
2. The name and title of the individual(s) who administered the nail care.
3. The condition of the resident ' s nails and nail bed.
4. Any difficulties in cutting the resident ' s nails.
5. Any problems or complaints made by the resident with his/her feet, or any complaints related to the procedure.
6. If the resident refused the treatment, the reason(s) why and the intervention taken.
7. The signature and title of the person recording the data.
The P&P further indicated the supervisor had to be notified if the resident refused nail care.
During a review of the facility ' s P&P titled, Supporting Activities of Daily Living (ADL), dated March 2018, the P&P indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide wound care services to promote healing and pr...
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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 wound care services to promote healing and prevent infection for one of seven sampled residents (Resident 3) by failing to:
1. Assess and monitor Resident 3 ' s Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present) on the left clavicle (collar bone) when Resident 3 was readmitted to the facility on [DATE].
2. Provide care and treatment to Resident 3 ' s Stage 3 pressure ulcer on the left clavicle from 1/17/2024 to 1/21/2024 (total of 5 days).
As a result of these failures, Resident 3 went five days without care and treatment for Resident 3 ' s pressure ulcer on the left clavicle which had the potential to worsen Resident 3's pressure ulcer and/or cause infection.
Cross reference F656
Findings:
During a review of Resident 3 ' s Face Sheet (admission Record- AR), the AR indicated the facility initially admitted Resident 3 on 10/27/2023 and readmitted the resident on 1/17/2024, with diagnoses of anoxic brain injury (stopping of blood flow into and within the brain due to injury), dependence on ventilator (the need for mechanical ventilation in order to breathe), and unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [non-viable yellow, tan, gray, green or brown tissue consists of dead cells] or eschar [dead tissue]) of other site (site not specified).
During a review of Resident 3 ' s Braden Risk Assessment Report (BRAB- assessment tool used to assess a resident ' s risk of developing a pressure ulcer), dated 10/28/2023, the BRAB indicated Resident 3 was at very high risk for developing a pressure ulcer.
During a review of Resident 3 ' s Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 11/2/2023, the MDS indicated Resident 3 had severely impaired cognition (ability to think, remember and function). The MDS indicated Resident 3 was dependent (helper does all of the effort) on the staff for oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, and personal hygiene). The MDS indicated Resident 3 was at risk for developing pressure ulcers and had two unstageable pressure ulcers present upon admission to the facility.
During a review of Resident 3 ' s Wound Assessment Report (WAR), dated 11/10/2023, the WAR indicated Resident 3 had Moisture Associated Skin Damage (MASD- inflammation or skin erosion caused by prolonged exposure to source of moisture) on the left clavicle, extending to the neck area. The WAR indicated the wound on the left clavicle was identified on 10/28/2023 and was present upon admission. The WAR indicated the wound had a small amount of serous (the clear, serum component of blood). The WAR indicated the assessment on 11/10/2023 was the admission assessment (14 days after initial admission).
During a review of Resident 3 ' s WAR, dated 12/28/2023, the WAR indicated Resident 3 had MASD on the left clavicle, extending to the neck area. The WAR indicated the left clavicular wound was identified on 10/28/2023. The WAR indicated the wound had a small amount of serous. The WAR indicated the assessment on 12/28/2023 was a weekly update.
During a review of Resident 3 ' s Situation-Background-Assessment-Recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations), dated 1/4/2024 at 6:21 am, the SBAR indicated Resident 3 had a temperature of 102.3 degrees Fahrenheit (F- unit of measurement). The SBAR indicated Resident 3 was sent to General Acute Care Hospital 1 (GACH 1) for further evaluation.
During a review of Resident 3 ' s GACH 1 Progress Notes, dated 1/16/2024, the Progress Notes indicated Resident 3 had a left upper, anterior (front) chest pressure injury (ulcer), present upon admission to GACH 1 on 1/4/2024.
During a concurrent interview and record review on 1/22/2024 at 2:30 pm with MDS Nurse (MDSN) 1, Resident 3 ' s physician orders and body assessment from 1/17/2024 were reviewed. MDSN 1 stated Resident 3 had no current orders to treat a left clavicle wound. MDSN 1 stated Resident 3 ' s body assessment indicated no wound to the left clavicle extending to the neck when the facility readmitted Resident 3 from GACH 1 on 1/17/2024.
During an interview on 1/22/2024 at 2:51 pm with Licensed Vocational Nurse (LVN) 6, LVN 6 stated LVN 6 did not treat a left clavicle wound during Resident 3 ' s treatment on the day of the interview. LVN 6 stated there were no physician orders to treat Resident 3 ' s left clavicle wound.
During an interview on 1/22/2024 at 3:21 pm with LVN 13, LVN 13 stated Resident 3 ' s readmission skin assessment (on 1/17/2024) was not done by a treatment nurse. LVN 13 stated Resident 3 ' s left clavicle wound was not assessed by the admitting nurse on 1/17/2024.
During an interview on 1/22/2024 at 3:26 pm with LVN 6, LVN 6 stated LVN 6 did not notice a wound on Resident 3 ' s left clavicle when LVN 6 treated Resident 3 ' s other wounds the morning of the interview.
During a concurrent observation and interview on 1/22/2024 at 3:37 pm with LVN 13, Resident 6 ' s left clavicle was observed. LVN 13 stated Resident 3 had a Stage 3 pressure ulcer on the left clavicle. LVN 13 stated there was 30 percent (%) slough and 70% granulation tissue (type of new connective tissue that protects wound surfaces microbes and further injury). LVN 13 stated Resident 3 ' s left clavicle pressure ulcer was over the bony prominence and measured 1.9 centimeters (cm- unit of measurement) length by 0.5 cm width, and 0.1 cm deep. LVN 13 stated Resident 3 ' s left clavicle wound was not assessed or treated since Resident 3 was readmitted to the facility on [DATE].
During an interview on 1/22/2024 at 4:57 pm with LVN 16, LVN 16 stated LVN 16 worked on 1/18/2024 as a treatment nurse. LVN 16 stated LVN 16 was not aware Resident 3 was readmitted to the facility. LVN 16 stated LVN 16 did not perform Resident 3 ' s admission skin assessment (on 1/17/2024). LVN 16 stated Resident 3 ' s medical record had other orders, so LVN 16 assumed another staff performed Resident 3 ' s admission skin assessment. LVN 16 stated not performing Resident 3 ' s admission skin assessment could worsen Resident 3 ' s left clavicle wound because it was not treated since Resident 3 ' s readmission on [DATE].
During an interview on 1/23/2024 at 1:25 pm with LVN 15, LVN 15 stated the treatment nurses were supposed to do weekly skin sweeps (assessments to check for resident skin breakdown). LVN 15 stated treatment nurses stopped doing skin sweeps on all residents during the summer of 2023. LVN 15 stated treatment nurses were not doing skin sweeps on all residents and were only treating residents with known pressure ulcers or other wounds. LVN 15 stated weekly skin sweeps needed to be performed on all residents to monitor residents for new skin breakdown as a preventative measure. LVN 15 stated not performing weekly skin sweeps put residents at risk for unassessed new pressures ulcers or skin condition and going untreated that could lead to medical decline.
During an interview on 1/24/2024 at 4:34 pm with the Director of Nursing (DON), the DON stated in general, charge nurses and treatment nurses were supposed to perform admission skin assessments on all residents. The DON stated if a resident went to the hospital and was readmitted , the admitting nurse was supposed to perform a skin assessment and the treatment nurse was supposed to do a reassessment to ensure no wounds or potential for wounds were missed. The DON stated if skin assessments were not being performed accurately, the resident ' s skin conditions would not be reflected accurately which could lead to a resident ' s condition deteriorating. The DON stated treatment nurses were supposed to perform skin sweeps but did not know the schedule.
During a review of the facility ' s policy and procedure (PP) titled, Prevention of Pressure Injuries, revised 4/2020, the PP indicated the purpose of the PP was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The PP indicated a risk assessment was to be performed within eight hours of admission for existing pressure injury risk factors. The PP indicated to conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, and indicated according to the resident ' s risk factors, and prior to discharge. The PP indicated to inspect the skin on a daily basis while performing or assisting with personal care or activities of daily living. The PP indicated to identify any signs of developing pressure injuries, and for darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency. The PP indicated to inspect pressure points (bony prominences). The PP indicated to evaluate, report and document potential changes in the skin. The PP indicated to review the interventions and strategies for effectiveness on an ongoing basis.
During a review of the facility ' s PP titled, Pressure Ulcers/Skin Breakdown – Clinical Protocol, revised 4/2018, the PP indicated the staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain consistent communication and collaboration with the dialysis facility regarding care and services for 1 of 3 sampled residents (Re...
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Based on interview and record review, the facility failed to maintain consistent communication and collaboration with the dialysis facility regarding care and services for 1 of 3 sampled residents (Resident 8) who was on dialysis (a procedure where a machine cleans the blood because the kidneys can no longer clean the blood) by failing to ensure:
1. Licensed Vocational Nurse 20 (LVN 20) reviewed Resident 8 ' s Dialysis Communication Record after Resident 8 came back from the dialysis center on 1/9/2024 and documented on the Communication Record any follow-up done to address the dialysis nurse report.
2. LVN 22 reviewed Resident 8 ' s Dialysis Communication Record after Resident 8 came back from the dialysis center on 1/16/2024 and documented on the Communication Record any follow-up done to address the dialysis nurse report.
These failures had the potential for Resident 8 to receive inadequate nursing care and treatment after Resident 8 received dialysis treatment.
Findings:
During a review of Resident 8 ' s Face Sheet (admission Record), the admission Record indicated the facility admitted Resident 8 on 9/3/2022 and readmitted Resident 8 on 1/22/2024 with diagnoses which included end stage renal disease. The admission Record indicated Resident 8 was dependent on dialysis.
During a review of Resident 8 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/8/2023, the MDS indicated Resident 8 ' s cognitive (ability to think and reason) status was intact and Resident 8 required substantial assistance with most activities of daily living (ADLs).
During a review of Resident 8 ' s Dialysis Communication Record, dated 1/9/2024, the Communication Record indicated, the dialysis nurse wanted the facility ' s Registered Nurse Supervisor to call the dialysis nurse. The Communication Record further indicated the dialysis nurse wanted the facility to provide Resident 8 good hygiene, to moisturize Resident 8 ' s dry skin, and to cut Resident 8 ' s nails because Resident 8 was consistently scratching Resident 8 ' s dialysis access line.
During an interview on 1/24/2024 at 12:05 pm with LVN 20, LVN 20 reviewed Resident 8 ' s Dialysis Communication Record, dated 1/9/2024. LVN 3 stated LVN 3 worked on 1/9/2024 and when LVN 3 read Resident 8 ' s Dialysis Communication Record on 1/9/2024, LVN 3 told a certified nursing assistant (CNA) to trim Resident 8 ' s nails. LVN 3 stated LVN 3 overlooked the rest of the information the dialysis nurse wrote on the Communication Record and LVN 3 did not inform the RN Supervisor on 1/9/2024 to call the dialysis nurse. LVN 3 stated, I don ' t think I saw that, I just filled out my post dialysis monitoring.
During a review of Resident 8 ' s Dialysis Communication Record, dated 1/16/2024, the Communication Record indicated, the dialysis nurse wanted the facility to know there was purulent (containing pus) discharge from Resident 8 ' s dialysis access line and that Resident 8 ' s blood was tested for bacteria and germs (disease-causing microorganisms). The Communication Record indicated, Resident 8 was seen by the physician and the physician ordered for Resident 8 ' s dialysis access line to be exchanged. The Communication Record further indicated Resident 8 was referred to the dialysis center ' s social worker due to poor hygiene.
During an interview on 1/24/2024 at 11:52 am with Registered Nurse Supervisor 3 (RN 3), RN 3 reviewed Resident 8 ' s Dialysis Communication Record, dated 1/16/2024. RN 3 stated RN 3 worked as the supervisor on 1/16/2024 and nobody showed her Resident 8 ' s Dialysis Communication Record and/or informed her of what the dialysis nurse wrote on the Communication Record.
During an interview on 1/24/2024 at 12:42 pm with the Assistant to the Director of Nursing (ADON), ADON stated licensed nurses were supposed to read what the dialysis nurse wrote on the Dialysis Communication Record, address what the dialysis nurse wrote, and then document the licensed nurse post dialysis monitoring and assessment.
During an interview on 1/24/2024 at 1:08 pm with the Director of Nursing (DON), the DON stated licensed nurses were supposed to read and follow-up on what the dialysis nurse documented on the Dialysis Communication Record after the resident comes back from dialysis. The DON stated after the resident comes back from dialysis, the licensed nurse was supposed to assess the resident ' s vital signs, assess the resident ' s dialysis access site, and read the Communication Record to find out if there were any new medications, recommendations, and follow-up needed. The DON stated it was important to review the dialysis nurse documentation on the Dialysis Communication Record to have continuity of care and coordinate care and services for the resident.
During a review of the facility ' s policy and procedure (P&P) titled, Access and Care of Hemodialysis Catheters, dated February 2023, the P&P indicated The nurse should document in the resident ' s medical record every shift as follows: 1. Location of catheter. 2. Condition of dressing (interventions if needed). 3. If dialysis was done during shift. 4. Any part of report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis.
During a review of the facility ' s P&P titled, Charting and Documentation, dated July 2017, the P&P indicated, All services provided to the resident .shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide proper nail hygiene to two of three sampled r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide proper nail hygiene to two of three sampled residents (Resident 9 and Resident 10) who were on dialysis (a procedure where a machine cleans the blood because the kidneys can no longer clean the blood) by failing to:
1. Ensure Resident 9 ' s and Resident 10 ' s fingernails were cleaned daily and kept trimmed.
2. Provide Resident 9 and Resident 10 assistance with personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, nail care, washing/drying face, and hands) as indicated by Resident 9 ' s and Resident 10 ' s activities of daily living (ADLs) care plan.
3. Ensure provision of nail care was documented in the resident ' s medical record according to the facility ' s Care of Fingernails/Toenails policy and procedure (P&P).
These failures had the potential for Resident 9 and Resident 10 to sustain skin injuries from scratching and to develop an infection.
Cross Reference F677
Findings:
1. During a review of Resident 9 ' s Face Sheet or admission Record (AR), the AR indicated the facility admitted Resident 9 on 10/26/2023 with diagnoses which included end stage renal disease (ESRD, when the kidneys can no longer clean the blood). The AR indicated Resident 9 was dependent on dialysis.
During a review of Resident 9 ' s ADL care plan, dated 10/26/2023, the ADL care plan indicated Resident 9 required extensive assistance with personal hygiene. The care plan indicated to monitor Resident 9 for ADLs needs and to assist Resident 9 with ADLs as needed.
During a review of Resident 9 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/1/2023, the MDS indicated Resident 9 ' s cognitive (ability to think and reason) status was intact and Resident 9 required moderate assistance with personal hygiene.
During a review Resident 9 ' s CNA Flow Sheet, dated 1/2024, the CNA flow sheet indicated there was no documented evidence nail care was provided to Resident 9.
2. During a review of Resident 10 ' s admission Record, the AR indicated the facility admitted Resident 10 on 12/15/17 and readmitted Resident 10 on 5/26/2023 with diagnoses which included end stage renal disease. The AR indicated Resident 10 was dependent on dialysis.
During a review of Resident 10 ' s ADL care plan, dated 12/14/2022, the ADL care plan indicated Resident 10 was dependent on staff to maintain personal hygiene. The ADL care plan indicated to monitor Resident 10 for ADLs needs and to assist Resident 10 with ADLs as needed.
During a review of Resident 10 ' s MDS, dated [DATE], the MDS indicated Resident 10 was nonverbal and did not express Resident 10 ' s ideas and needs. The MDS indicated Resident 10 was dependent on staff to maintain personal hygiene.
During a review Resident 10 ' s CNA Flow Sheet, dated 1/2024, the CNA flow sheet indicated there was no documented evidence nail care was provided to Resident 10.
During an interview on 1/22/2024 at 1:41 pm with Licensed Vocational Nurse 16 (LVN 16), LVN 16 stated all nursing staff (RNs, LVNS, CNAs) monitored residents ' nails every time nursing staff provided care to residents. LVN 16 stated all nursing staff trimmed and cleaned residents ' nails.
During a concurrent observation and interview on 1/22/2024 at 1:53 pm with Resident 9 in Resident 9 ' s room, Resident 9 ' s fingernails were long and dirty. Resident 9 stated Resident 9 did not know who and how often Resident 9 ' s nails were trimmed and cleaned.
During a concurrent observation and interview on 1/22/2024 at 1:58 pm with LVN 16 in Resident 9 ' s room, Resident 9 was observed scratching Resident 9 ' s right chest where Resident 9 ' s dialysis access line was. LVN 16 pulled down Resident 9 ' s gown to check on Resident 9 ' s dialysis access line and noted there was no dressing that covered the dialysis access line site. LVN 16 stated Resident 9 occasionally removed Resident 9 ' s dialysis access line site dressing. LVN 16 noted Resident 9 ' s fingernails were long and dirty. LVN 16 stated Resident 9 ' s fingernails could use a little cleaning and cutting. LVN 16 stated nursing staff trimmed and cleaned residents ' nails every week.
During a concurrent observation and interview on 1/22/2024 at 2:11 pm with Registered Nurse Supervisor 3 (RN 3) in Resident 9 ' s room, RN 3 noted Resident 9 ' s fingernails were long and dirty. RN 3 stated it was important for residents who were on dialysis to have clean and short nails because residents could scratch and touch their dialysis access line and their dirty nails could become a source of infection.
During an interview on 1/22/2024 at 2:26 pm with Certified Nursing Assistant 16 (CNA 16), CNA 16 stated CNAs trimmed and cleaned residents ' nails every Sunday. CNA 16 stated CNA 16 checked residents ' nails every time CNA 16 provided care to residents. CNA 16 stated CNA 16 would offer to trim and clean residents ' nails, but residents sometimes refused. CNA 16 stated CNA 16 showered and offered to cut and clean Resident 9 ' s nails earlier that day but Resident 9 refused. CNA 16 stated it was important for residents to have clean and short nails to prevent scratches, skin tears, and infection.
During a concurrent observation and interview on 1/23/2024 at 12:35 pm with LVN 18 in Resident 10 ' s room, Resident 10 was noted to have a dialysis access line on Resident 10 ' s left thigh. LVN 18 noted Resident 10 ' s fingernails were long and dirty. LVN 18 stated all licensed nurses and CNAs were supposed to check the residents ' nails every time licensed nurses and CNAs provided care to residents. LVN 18 stated licensed nurses and CNAs should trim and clean residents ' nails, as soon as licensed nurses and CNAs noted residents ' nails were long and dirty. LVN 18 stated it was important for residents to have clean and short nails to prevent residents from scratching and to prevent infection.
During an interview on 1/23/2024 at 12:43 pm with CNA 17, CNA 17 stated CNAs needed to cut and clean residents ' nails as soon as CNAs noted the residents ' nails were long and dirty. CNA 17 stated CNA 17 noted Resident 10 ' s nails were long and dirty when CNA 17 cleaned Resident 10 ' s hands earlier that day and planned to cut and clean Resident 10 ' s nails later that day. CNA 17 stated CNAs checked residents ' nails every time CNAs provided care to residents. CNA 17 stated CNAs did not provide resident showers on Thursdays because CNAs were supposed to only shave residents and provide nail care on Thursdays.
During an interview on 1/23/2024 at 12:57 pm with CNA 18, CNA 18 stated nail care was done as needed when resident ' s nails were long and dirty, but CNAs checked residents ' nails every day when CNAs provided care. CNA 18 stated CNAs did not provide resident showers on Thursdays because CNAs were supposed to only shave residents, do nail care, and clean and organize residents ' closets every Thursday.
During an interview on 1/23/2024 at 2:34 pm with Minimum Data Set Nurse 1 (MDSN 1), MDSN 1 reviewed Resident 9 ' s and Resident 10 ' s medical records. MDSN 1 stated nail care was not documented in the CNA Flow Sheet or in the progress notes.
During an interview on 1/23/2024 at 3:48 pm with the Director of Staff Development (DSD), the DSD stated nursing staff were supposed to do nail care as soon as nursing staff noticed a resident ' s nails to be long and dirty. The DSD stated nail care was part of ADL and personal hygiene, and CNAs were supposed to check residents ' nails every time they provided ADL care. The DSD stated there was one day a week in the facility when CNAs did not provide showers so that CNAs could provide nail care. The DSD stated nail care was provided on Thursdays, but one Station (patient care area where residents reside in the facility) provided nail care on Sundays. The DSD stated it was important for residents to have clean and short nails to prevent from getting injured and because residents sometimes put their fingers in their mouths and used their hands to eat.
During an interview on 1/24/2024 at 1:08 pm with the Director of Nursing (DON), the DON stated CNAs needed to look at residents ' nails when CNAs provided residents daily care every shift. The DON stated residents ' nails needed to be clean and trimmed to prevent scratches and infection.
During a review of the facility ' s P&P titled, Care of Fingernails/Toenails, dated February 2018, the P&P indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The P&P indicated to review the resident ' s care plan prior to providing nail care, and to provide daily cleaning and regular trimming as part of nail care. The P&P indicated the following information should be recorded in the resident ' s medical record:
1. The date and time that nail care was given.
2. The name and title of the individual(s) who administered the nail care.
3. The condition of the resident ' s nails and nail bed.
4. Any difficulties in cutting the resident ' s nails.
5. Any problems or complaints made by the resident with his/her feet, or any complaints related to the procedure.
6. If the resident refused the treatment, the reason(s) why and the intervention taken.
7. The signature and title of the person recording the data.
The P&P further indicated the supervisor had to be notified if the resident refused nail care.
During a review of the Centers for Disease Control and Prevention ' s (CDC, the national public health agency of the United States) guideline titled, Nail Hygiene, dated 6/15/2022, the CDC guideline indicated, Appropriate hand hygiene includes diligently cleaning and trimming fingernails, which may harbor dirt and germs and can contribute to the spread of some infections . Fingernails should be kept short, and the undersides should be cleaned frequently with soap and water. Because of their length, longer fingernails can harbor more dirt and bacteria than short nails, thus potentially contributing to the spread of infection .
[Source: https://www.cdc.gov/hygiene/personal-hygiene/nails.html]
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 F0678
(Tag F0678)
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 to failed to follow their policy and procedure (PP) titled, Emergency Procedu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to failed to follow their policy and procedure (PP) titled, Emergency Procedure- Cardiopulmonary Resuscitation, by failing to:
1. Ensure three (3) Certified Nursing Assistants (CNAs) 5, 8, 12, eight (8) Licensed Vocational Nurses (LVNs) 1, 2, 3, 6, 10, 21, 23, and 24, and two (2) Respiratory Therapists (RTs) 2 and 4, had updated (not expired) Basic Life Support (BLS- set of essential emergency procedures designed to sustain life in victims experiencing cardiac arrest) certification cards while working at the facility.
2. Ensure Certified Nursing Assistant (CNA) 15 received BLS certification from either the American Red Cross (ARC) or the American Heart Association (AHA).
These failures had the potential for all residents who had a full code status (resident ' s heart stopped beating and/or the resident stopped breathing, the resident or their representative wishes for all lifesaving procedures to be provided to keep them alive) to be put at risk for not receiving the most up-to-date CPR or accurate CPR training in the event the residents (in general) needed life-sustaining treatment (treatment that serves to prolong life without reversing the underlying medical condition).
Findings:
1. During a concurrent interview and record review on [DATE] at 4:37 pm, with the Director of Staffing Development (DSD), the facility ' s Staff BLS Certification List was reviewed. The DSD stated the DSD kept track of BLS certifications for staff. The DSD stated staff had to be trained in CPR in the event a resident had respiratory failure (respiratory arrest- failure of the lungs to oxygenate blood), choking (severe difficulty in breathing because of a constricted or blocked throat or lack of air), and/or cardiac arrest (sudden stopping of function of the heart). The DSD stated CPR helped provide oxygen to the body and circulate blood. The DSD stated CPR was important because CPR helped to revive (bring back to life) a resident. The DSD stated it was important for staff to have current (not expired) BLS certification because if a resident coded (respiratory or cardiac arrest), starting CPR immediately increased a resident ' s chances of survival. The DSD stated there were six (6) staff (CNAs 5, 8, and 12 and LVNs 21, and 23) with expired BLS certifications working in the facility or scheduled to work on the day of the interview ([DATE]).
During a concurrent interview and record review on [DATE] at 11:44 am, with the DSD, the facility ' s Staff BLS Certification List was reviewed. The DSD stated there were three (3) staff that were sent home or told not to come to work for having expired BLS certifications (CNAs 5, 8 and LVN 2). The DSD stated eight (8) additional staff had expired BLS certifications on the day of the interview ([DATE], CNA 12, LVNs 1, 3, 6, 10, 23 and RT 2 and 4).
2. During a record review on [DATE] at 12:05 pm, the copies of staffs ' BLS certification cards were reviewed. CNA 15 ' s BLS certification card indicated the BLS certification was not obtained from the ARC or AHA.
During an interview on [DATE] at 4:19 pm, with the Director of Nursing (DON), the DON stated every staff who worked in the nursing department (RNs, LVNs, and CNAs) were required to have a current BLS certification from either the ARC or the AHA. The DON stated all RTs were required to have current BLS certifications. The DON stated staff were supposed to be BLS certified so they could respond appropriately if a resident went into cardiac arrest. The DON stated if staff were performing patient care (prevention, treatment, and management of illness and the preservation of physical and mental well-being), staff were supposed to have updated BLS certification to indicate their CPR skills had been evaluated or reevaluated. The DON stated the DSD was supposed to ensure staff got recertified in CPR before their BLS certification expired. The DON stated staff should not be working with an expired BLS certification.
During a concurrent interview and record review on [DATE] at 12:10 pm, with the DSD, the PP titled, Emergency Procedure- Cardiopulmonary Resuscitation, was reviewed. The DSD stated the DSD was not aware staff needed to have BLS certification from either ARC or AHA.
During an interview on [DATE] at 4:34 pm, with the DON, the DON stated if staff were working with an expired BLS certification, they may not be able to provide the most up to date CPR and it could potentially affect a coding resident ' s outcome and the resident could die.
During a review of the facility ' s PP titled, Emergency Procedure- Cardiopulmonary Resuscitation, revised 2/2018, indicated personnel have completed training on the initiation of CPR and BLS, including defibrillation (shocking of heart), for victims of sudden cardiac arrest. The PP indicated staff were to obtain and/or maintain ARC or AHA certification in BLS and CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. The PP indicated the CPR team would include at least one nurse, one LVN, and two CNAs, all of whom have received training and certification in CPR/BLS.
During a review of the facility ' s job description, Charge Nurse- RN/LVN, undated, the job description indicated RNs and LVNs had current CPR certification. The job description indicated the RNs and LVNs initiated CPR and assisted with code procedures as directed by charge nurse.
During a review of the job description titled, Certified Nursing Assistant- Resident Services, undated, the job description indicated CNAs initiated CPR and assisted with code procedures as directed by charge nurse.
Dec 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure the environment for one (Resident 7) of one resident, reviewed for elopement, was free of accident hazards and Residen...
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Based on observation, interview, and record review, the facility failed to ensure the environment for one (Resident 7) of one resident, reviewed for elopement, was free of accident hazards and Resident 7 was provided adequate supervision.
As a result of this deficient practice, Resident 7 eloped from the facility possibly through a double glass exit door by her room that led to the outside of the facility which put Resident 7 at risk for injury from being on her own and unsupervised outside of the facility.
Findings:
During a review of Resident 7's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 7 on 12/14/23 at 5:51 PM, with diagnoses that included schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), and dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).
During a review of Resident 7's History and Physical (H&P), dated 12/15/23, the H&P indicated Resident 7 did not have the capacity to understand and make decisions.
During a review of Resident 7's Elopement Risk Assessment, dated 12/15/23, indicated Resident 7 had a total score of 9. The Elopement Risk Assessment form indicated that a total score above 10 represents a high risk for elopement.
During a review of Resident 7's Care Plan: Elopement dated 12/14/23, the Care Plan indicated Resident 7 was at risk for injuries secondary to elopement. The Care Plan goal indicated Resident 7 will not elope out of the facility and for staff to recognize if resident has a high risk of elopement. The interventions included for the staff to monitor resident's location with visual check at least every 2 hours (q2h) and provide secured doors and frequent visual checks.
During a review of Resident 7's Departmental Notes (DN) dated 12/15/23 at 6:12 PM, the DN indicated, on 12/15/23 at 5:30 PM, Licensed Vocational Nurse 2 (LVN 2) reported that Resident 7 was missing. The DN indicated a search was immediately done and three staff drove around the facility but could not find Resident 7.
During a review of Resident 7's DN dated 12/16/23 at 3:00 PM, the DN indicated that Resident 7 was back at the facility at 10:45 AM and was transferred to the facility's Dementia (locked) Unit. The DN indicated Resident 7 was found unharmed but refused body check.
During an interview on 12/28/23 at 3:30 PM with LVN 2, LVN 2 stated he was the charge nurse when Resident 7 eloped. LVN 2 stated, Resident 7's room was next to a double glass exit door, but he was not sure if Resident 7 left the facility through the double glass door. LVN 2 stated, when he checked Resident 7 around 4:30 PM to pass her medication and give her food tray, Resident 7's bed was empty.
During a concurrent observation and interview on 12/28/23 at 3:35 PM with LVN 2 and LVN 3, the double glass exit door by Resident 7's room was noted to be unlocked. LVN 2 opened the double glass exit door and the door alarm did not sound. LVN 3 verified that the door was unlocked, and the alarm did not sound when the door was opened. LVN 3 stated, nobody used this door to enter or exit the facility. LVN 3 stated, the door was supposed to be locked and the alarm should have been working.
During an interview on 12/28/23 at 3:40 PM with the Maintenance Assistant (MA), MA verified and stated the double glass exit door was not locked and the alarm when the door was opened did not work. MA stated, the alarm on the door should be working all the time.
During an interview on 12/28/23 at 3:45 PM with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated, he checked Resident 7's bed around 4:30 PM and noticed that it was empty. CNA 4 stated, he did not report Resident 7 missing to the charge nurse right away because he thought Resident 7 was in the activities room. CNA 4 stated, he should have searched for Resident 7 and reported to the charge nurse right away when he could not find Resident 7. CNA 4 stated, it was his responsibility to know the whereabouts of the residents assigned to him.
During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, revised March 2019, the P&P indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for resident. The P&P indicated if a resident is identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.
Nov 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 update the inventory list for one of three sampled residents (Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update the inventory list for one of three sampled residents (Resident 2) by failing to follow the facilities policy and procedure (P&P) titled, Personal Property.
This deficient practice had the potential for theft or loss of Resident 2's personal belongings.
Findings:
A review of Resident 2's Face Sheet indicated Resident 2 was most recently re-admitted to the facility on [DATE]. Resident 2's diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your own) and asthma (a long-term condition that affects the airways in the lungs).
A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/2/23, indicated Resident 2 was understood by others and had the ability to understand others.
A review of Resident 2's Resident Inventory of Personal Effects, dated 5/15/23, did not indicate a laptop computer on the inventory list.
During an interview on 11/7/23 at 11:23 am, Resident 2 reported her laptop computer missing.
During an interview on 11/7/23 at 4 pm and on 11/8/23 at 1:16 pm, with the Social Services Director (SSD), SSD stated Resident 2's two laptop computers were not on Resident 2's inventory list as of 11/7/23. SSD stated Resident 2's friend (F1) was going to fix Resident 2's two laptop computers, returned the two laptop computers back to Resident 2 on 11/4/23. SSD stated she added Resident 2's two laptop computers to update Resident 2's inventory list on 11/7/23. SSD further stated inventory lists should be updated to know what the residents have in their personal belongings. SSD also stated it was the responsibility of both the social services department and the nursing department to update the inventory lists.
A review of the facility's P&P titled, Personal Property, revised in August 2022, indicated resident belongings are treated with respect by facility staff, regardless of perceived value. The P&P indicated the resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. The facility promptly investigates any complaints of misappropriation or mistreatment of resident property.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) wh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) who had long and dirty fingernails, was provided nail care.
This deficient practice placed Resident 3 at risk of skin breakdown and developing an infection.
Findings:
During a review of Resident 3's Face Sheet indicated Resident 3 was most recently admitted to the facility on [DATE]. Resident 3's diagnoses included end stage renal disease (the last stage of long-term kidney disease in which the kidneys can no longer function on their own), dependence on renal dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to), and muscle weakness.
During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/8/2023, indicated Resident 3 was understood by others and had the ability to understand others. The MDS indicated Resident 3 required total dependence (full staff performance every time during entire seven-day period) and one-person physical assist with personal hygiene.
During a review of Resident 3's Care Plan: Renal Dialysis, dated 9/8/2023, indicated Resident 3's dialysis site was a permacath (a special catheter [flexible tube] used for short-term dialysis treatment that is placed inside a blood vessel in the neck or just under the collarbone and then threaded into the right side of the heart) on the right side of Resident 3's chest.
During a review of Resident 3's Care Plan: ADL (Activities of Daily Living) with a re-evaluated date of 9/2023, indicated an approach/plan for Resident 3 was to ensure Resident 3 had clean and trimmed fingernails.
During a concurrent observation and interview on 11/7/2023 at 2:45 pm, Resident 3 had long fingernails that had dirt under the nails. Resident 3 stated he usually liked his fingernails to be short.
During an interview on 11/7/2023 at 3:39 pm, Licensed Vocational Nursing 1 (LVN 1) stated Resident 3's fingernails were kind of dirty. LVN 1 stated if Resident 3 scratched Resident 3's self and had long, dirty nails, it could cause an infection at Resident 3's dialysis site.
During an interview on 11/8/2023 at 3:10 pm, LVN 2 stated Resident 3 had the tendency to scratch the permacath site. LVN 2 stated the importance of having clean, short nails was to prevent infection if Resident 3 scratched self.
During a review of the facility's policy and procedure (P&P) titled, Care of Fingernails/Toenails, revised in February 2018, indicated the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Preparation: review the resident's care plan to assess for any special needs of the resident. Documentation: The following information should be included in the resident's medical record: the date and time that nail care was given; the name and title of the individual(s) who administered the nail care; the condition of the resident's nails and nail bed; any difficulties in cutting the resident's nails; any problems or complaints made by the resident with his/her hands or feet or any complaints related to the procedure; if the resident refused the treatment, the reason(s) why and the intervention taken; and the signature and title of the person recording the data.
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
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 follow their policies and procedures (P&P) titled, De...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policies and procedures (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection and CPAP (continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while you sleep) / BiPAP (bilevel positive airway pressure - a machine that helps you breathe) Support, by:
1. Failing to ensure a nasal cannula (NC - a device that delivers extra oxygen through a tube and into your nose) tubing was changed every seven days for one of two sampled residents (Resident 1).
2. Failing to ensure a No Smoking sign was posted for two of six rooms (R2 and R3) with oxygen concentrators (a medical device that gives you extra oxygen) being used.
These deficient practices had the potential to result in a respiratory infection to Resident 1 and the potential for risk of fire due to oxygen use.
Findings:
1. During a review of Resident 1's Face Sheet indicated Resident 1 was readmitted to the facility on [DATE]. Resident 1's diagnoses included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), generalized edema (swelling caused by too much fluid trapped in the body's tissues), and heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen).
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/14/2023, indicated Resident 3 was understood by others and had the ability to understand others.
A review of Resident 1's Physician Orders for the month of November 2023 indicated Resident 1 had an order for oxygen at two liters per minute (LPM - flow rate of a gas) via NC as needed for COPD.
During a concurrent observation and interview on 11/6/2023 at 1:27 pm., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 was observed replacing Resident 1's old NC that was in a plastic bag. The old plastic bag was noted with a date of 10/8/2023. The new bag was noted with a date of 11/6/2023. Resident 1 stated the facility did not change the NC. LVN 3 stated it was supposed to be changed every week.
During a review of the facility's P&P titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised in November 2011, indicated the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The P&P indicated a step in the procedure for infection control considerations related to oxygen administration included to change the oxygen cannula and tubing every seven days, or as needed.
2. During an observation on 11/6/2023 at 2:33 pm, six rooms (R1, R2, R3, R4, R5, R6) had oxygen concentrators being used. Rooms R2 and R3 did not have No Smoking signs posted at the doors.
During an interview on 11/6/2023 at 4:18 pm, Respiratory Therapist (RT) stated the rooms that had oxygen in use were supposed to have a No Smoking sign at the doors.
During an interview on 11/6/2023 at 4:56 pm, the Director of Nursing (DON) stated the importance of having a No smoking sign on the door was due to oxygen use and safety reason.
During a review of the facility's P&P titled, CPAP/BiPAP Support, revised in March 2015, indicated the purpose of the P&P was to promote resident comfort and safety. The P&P indicated the equipment and supplies needed for the resident's room was a No Smoking sign. The P&P also indicated a step in the procedure was to explain the safety precautions required during oxygen administration.
Oct 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Change in a Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by not notifying one of three sampled residents (Resident 3's) Representative 1 (R1) when Resident 3 was transferred to a General Acute Care Hospital 1 (GACH 1).
This failure resulted in the violation of Resident 3's right to notify Resident 3's R1 of any changes of condition/status to Resident 3.
Findings:
During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of lymphoid leukemia (cancer of the blood and bone marrow), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and lack of coordination (not able to move different parts of the body together well or easily). The Face sheet listed R1 as a contact person for Resident 3.
During a review of Resident 3's admission Nursing Assessment, dated 10/2/23, the assessment indicated Resident 3 was understood by others and had the ability to understand others. The assessment indicated Resident 3's cognitive (relating to the mental process involved in knowing, learning, and understanding things) skills for daily decision making was moderately impaired (weakened state or condition), made poor decisions, and required cues (a signal for a person to say or do something)/supervision.
During a review of Resident 3's Physician's Telephone Order, dated 10/5/23 at 1:30 pm, the telephone order indicated Resident 3 to be transferred to the emergency room (ER) for further evaluation and for computed tomography (CT - a diagnostic imaging exam that uses X-ray technology to produce images of the inside of the body) of Resident 3's head due to a bump/discoloration on Resident 3's right side of the head/temporal (relating to the temples or the sides of the skull) area.
During a review of the facility's Nursing Census Daily Recap, dated 10/5/23, the Daily Recap indicated Resident 3 was discharged to GACH 1 on 10/5/23 at 3:50 pm.
During a review of Resident 3's Departmental Notes for the month of October 2023, there was no documented nurses note that indicated R1 was notified of Resident 3's transfer to GACH 1 on 10/5/23.
During an interview on 10/19/23 at 3:23 pm with R1, R1 stated no one from the facility contacted R1 to inform him that Resident 3 was transferred to GACH 1.
During an interview on 10/23/23 at 2:34 pm with the Acting Director of Nursing (ADON), ADON stated Resident 3's nurses notes did not indicate when Resident 3 was transferred to GACH 1 and the note did not indicate R1 was notified of the transfer to GACH 1.
During an interview on 10/23/23 at 2:54 pm with Registered Nurse 1, RN 1 stated RN 1 would usually call the family member if a resident was transferred to the hospital. RN 1 stated RN 1 did not document on the nurses notes about the hospital transfer and about notifying R1.
During an interview on 10/23/23 at 3:14 pm with ADON, ADON stated if the staff did not document it, it did not happen.
During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised in May 2017, the P&P indicated the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Unless otherwise instructed by the resident, a nurse will notify the resident's representative when it is necessary to transfer the resident to a hospital/treatment center.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a staff (Licensed Vocational Nurse 1 [LVN 1]) properly sanitized a glucometer machine (a small, portable machine that ...
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Based on observation, interview, and record review, the facility failed to ensure a staff (Licensed Vocational Nurse 1 [LVN 1]) properly sanitized a glucometer machine (a small, portable machine that is used to measure how much glucose [a type of sugar] is in the blood) between two of three sampled residents (Resident 1 and Resident 2).
This deficient practice had the potential to increase the risk of spreading infection between Resident 1 and Resident 2.
Findings:
During an observation on 10/19/23 at 12:30 pm in Resident 1 and Resident 2's room, LVN 1 was observed checking Resident 2's blood sugar with a glucometer machine and test strip (a small plastic strip used to test and measure blood glucose levels). After LVN 1 checked Resident 2's blood sugar, LVN 1 discarded the test strip and placed the glucometer machine on top of the medical cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense medications and medical supplies and equipment). LVN 1 prepared the glucometer machine by putting a new test strip and proceeded to check Resident 1's blood sugar without sanitizing the glucometer machine after LVN 1 used it on Resident 2.
During an interview on 10/19/23 at 12:45 pm with LVN 1, LVN 1 stated the process when checking blood sugar between residents was to sanitize the glucometer machine after each use on a resident. LVN 1 stated she should have sanitized the glucometer machine after using it on Resident 2 and Resident 1.
During an interview on 10/19/23 at 4:50 pm with the Acting Director of Nursing (ADON), ADON stated staff should be sanitizing the glucometer machine after each use between residents to prevent the spread of infection.
During a record review of the facility's policy and procedure (P&P) titled, Obtaining a Fingerstick Glucose Level, revised in October 2011, the P&P indicated the purpose of the procedure is to obtain a blood sample to determine the resident's blood glucose level. The following equipment and supplies will be necessary when performing this procedure: disinfected blood glucose meter (glucometer) with sterile lancet. Steps in the procedure included: always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice.
Oct 2023
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 1 and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 1 and Resident 2), who had diabetes mellitus (disease that results in too much sugar in the blood), received care, treatment, and services in accordance with the care plan, the physician's order, and the facility's policy and procedures by failing to ensure:
1. Medications and treatment were provided according to the physician's orders.
2. Residents' blood sugar level was documented in the clinical record.
These failures had the potential to result in uncontrolled blood sugar levels, administration of inaccurate amounts of insulin (medication used to treat high blood sugar), and health complications resulting in hospitalization for Resident 1 and Resident 2.
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/27/2023 with diagnoses that included diabetes mellitus.
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/30/2023, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for decision making was intact and Resident 1 verbalized Resident 1's needs. The MDS indicated Resident 1 required staff supervision with bed mobility, transfers (moving a resident from one flat surface to another), dressing, eating, toileting, and personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, washing/drying face, and hands). The MDS indicated Resident 1 required limited assistance of one person to walk.
During a review of Resident 1's Care Plan, dated 5/27/2023, the Care Plan indicated Resident 1 was at risk for hyperglycemia (high blood sugar), or hypoglycemia (low blood sugar) related to diabetes mellitus. The Care Plan indicated the nursing interventions included: to provide the resident medications and insulin according to the physician's order, and to monitor blood sugar (BS) according to the physician's order.
During a review of Resident 1's current Physician Orders, for the month of October 2023, the Physician Orders indicated the following orders:
- metformin (oral medication used to treat high blood sugar) 1000 milligrams (mg, unit of measure) by mouth twice a day before meals at 6:30 am and at 4:30 pm. The order indicated there were no parameters to hold Metformin, start date of 5/27/2023.
- regular insulin (short-acting insulin) injection per sliding scale (indicates dose of insulin based on blood glucose level): if BS 0-200 give 0 units; BS 201-250 give 2 units; BS 251-300 give 4 units; BS 301-350 give 6 units; BS 351-399 give 8 units, to give subcutaneously (SQ, into the fat under the skin) before meals at 6:30 am, at 11:30 am, and at 4:30 pm and at bedtime (9 pm). The order indicated to notify the physician if the BS was less than 70 or greater or equal to 400, the start date was 5/28/2023.
- insulin glargine (long-acting insulin) 25 units injection SQ at bedtime (9 pm). The order indicated, do not give if BS was below 100, start date of 8/16/2023.
During a review of Resident 1's Medication Administration Record (MAR), dated 8/1/2023 to 8/31/2023, the MAR indicated:
- Resident 1's BS was not documented and regular insulin injection per sliding scale was not given on 8/4/2023 at 11:30 am, on 8/11/2023 at 11:30 am, on 8/19/2023 at 4:30 pm, and on 8/19/2023 at 9 pm.
- The physician was not notified about Resident 1's BS level of 58 on 8/15/2023 at 11:30 am.
- Metformin 1000 mg was not administered to Resident 1 on 8/16/2023 at 6:30 am due to BS of 80, on 8/19/2023 at 4:30 pm with no BS recorded, on 8/22/2023 at 6:30 am due to BS of 80, and on 8/31/2023 at 6:30 am due to BS of 102.
During a review of Resident 1's MAR, dated 9/1/2023 - 9/30/2023, the MAR indicated:
- Resident 1's BS was not documented and regular insulin injection per sliding scale was not given on 9/20/2023 at 11:30 am and on 9/21/2023 at 6:30 am.
- Metformin 1000 mg was not given to Resident 1 on 9/24/2023 at 4:30 pm due to BS of 73.
- Insulin glargine 25 units injection was given with BS of 98 on 9/14/2023 at 9 pm.
During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 11/22/2022 with diagnoses which included diabetes mellitus.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for decision making was intact and Resident 2 verbalized Resident 2's needs. The MDS indicated Resident 2 was totally dependent on one person for bed mobility, dressing, and toilet use, and was totally dependent on two or more persons for transfers.
During a review of Resident 2's Care Plan, dated 9/19/2023, the Care Plan indicated Resident 2 was at risk for hyperglycemia, or hypoglycemia, related to diabetes mellitus. The Care Plan indicated the nursing interventions included: to provide the resident medications and insulin according to the physician's order, and to the BS according to the physician's order.
During a review of Resident 2's current Physician Orders, for the month of October 2023, the Physician Orders indicated:
- insulin lispro (fast-acting insulin) 10 units injection SQ three times daily at 6 am, at 2 pm, and at 10 pm, start date of 8/4/2023.
- insulin lispro injection per sliding scale: if BS 0-200 give 0 units; BS 201-250 give 2 units; BS 251-300 give 4 units; BS 301-350 give 6 units; BS 351-399 give 8 units, to give SQ three times daily with meals at 7 am, at 12 pm, and at 5 pm. Notify physician if BS is less than 70 or greater than 400, start date of 8/4/2023
During a review of Resident 2's MAR, dated 8/1/2023 to 8/31/2023, the MAR indicated:
- Resident 2's insulin lispro 10 units injection was not given on 8/20/2023 at 2 pm, and on 8/22/2023 at 2 pm.
- Resident 2's blood sugar was not documented and insulin lispro injection per sliding scale was not given on 8/18/2023 at 7 am and on 8/22/2023 at 12 pm.
During a review of Resident 2's MAR, dated 9/1/2023 to 9/30/2023, the MAR indicated Resident 2's insulin lispro 10 units injection was not given on 9/1/2023 at 2 pm.
During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 10/2/2023 at 4:10 pm, LVN 2 checked Resident 1's BS. LVN 2 stated LVN 2 would not give Resident 1 metformin 1000 mg because Resident 1's BS level was 87.
During a concurrent interview and record review with the Director of Nursing (DON) on 10/3/20 at 4:15 pm, the DON reviewed Resident 1's Physician's Orders, Resident 1's August 2023 MAR, and Resident 1's September 2023 MAR. The DON stated licensed nurses should record the resident's BS level in the MAR and must give medications according to the physician's orders. The DON stated licensed nurses should notify the physician whenever medications were not administered to the resident. The DON stated licensed nurses must follow the parameters on when to notify the physician according to the physician's orders.
During a concurrent interview and record review with LVN 2 on 10/3/2023 at 4:45 pm, LVN 2 stated, on 9/14/2023 at 9 pm, she gave Resident 1 insulin glargine 25 units injection per Resident 1's request and when Resident 1's BS level was 98. LVN 2 stated LVN 2 should have held the insulin glargine on 9/14/2023 at 9 pm according to the physician's orders.
During a phone interview with LVN 3 on 10/4/2023 at 10:15 am, LVN 3 stated on 9/18/2023 at 9 pm and on 9/29/2023 at 9 pm, she did not give insulin glargine to Resident 1 because Resident 1's BS level was under 100. LVN 3 stated LVN 3 knew the physician's order for Resident 1 was to hold the insulin glargine for BS level under 100. LVN 3 stated LVN 3 always gave Resident 1 metformin 1000 mg because there was no parameter to hold metformin 1000 mg. LVN 3 stated it was important to document accurately on the resident's clinical record so that any medical provider who reviewed the resident's record would have knowledge of what was going on with the resident.
During a phone interview with Resident 1's Primary Physician (MD 1) on 10/4/2023 at 1:13 pm, MD 1 stated whenever he wanted to know about Resident 1's BS level, he usually asked the licensed nurses. MD 1 stated it was important to document the resident's BS level in the clinical record so he could evaluate the resident's BS level trend and adjust the resident's medications if he needed to.
During a concurrent interview and record review with the Director of Quality Improvement (DQI) on 10/4/2023 at 2:41 pm, the DQI reviewed the August 2023 and September 2023 MARs for Resident 1 and Resident 2. The DQI stated licensed nurses were supposed to initial the MAR right after they gave the resident their medications. The DQI stated when a resident refused to take a medication and/or when a medication was not given to the resident, the licensed nurses had to notify the physician. The DQI stated medications must be given according to the physician's orders and should not be held without a physician's order. The DQI stated BS level for insulin sliding scale should be documented in the MAR. The DQI stated it was important to check and document the resident's BS level in the resident's record so the licensed nurse would know what to do and how much insulin to give the resident per the sliding scale. The DQI stated the only record the physicians look at to determine the resident's trend in BS level was the MAR.
During a review of the facility's policy and procedure (P&P) titled, Nursing Care of the Older Adult with Diabetes Mellitus, dated November 2020, the P&P indicated to follow the physician's orders for blood glucose monitoring.
During a review of the facility's P&P titled, Obtaining a Fingerstick Glucose Level, dated October 2011, the P&P indicated the person performing the fingerstick should record the date and time the procedure was performed, the name and title of the individual(s) who performed the procedure .the blood sugar results, the nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages), and the signature and title of the person recording the data.
During a review of the facility's P&P titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame .medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose, the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, the injection site (if applicable), any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed, and the signature and title of the person administering the drug.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medications and complete documentations fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medications and complete documentations for two of five sampled residents (Resident 1 and Resident 2) according to the facility ' s policy and procedure and failed to document by failing to ensure:
1. Medications and treatment were provided according to the physician ' s orders.
2. Residents ' blood sugar level was documented in the clinical record.
These failures had the potential for Resident 1 ' s and Resident 2 ' s blood sugar level to not be controlled and monitored, for Resident 1 and Resident 2 to receive inaccurate amounts of insulin (medication used to treat high blood sugar), and possibly lead to health complications resulting in hospitalization.
Cross reference F684
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 5/27/2023 with diagnoses which included diabetes mellitus.
During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/30/2023, the MDS indicated Resident 1 ' s cognitive (ability to think and reason) skills for decision making was intact and she verbalized her needs. The MDS indicated Resident 1 required staff supervision with bed mobility, transfer, dressing, eating, toileting, and personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, washing/drying face, and hands). The MDS indicated Resident 1 required limited assistance of one person to walk.
During a review of Resident 1 ' s current Physician Orders, for the month of October 2023, the Physician Orders indicated:
> an order, with a start date of 5/27/2023, for metformin (oral medication used to treat high blood sugar) 1000 milligrams (mg, unit of measure) by mouth twice a day before meals at 6:30 am and at 4:30 pm. The order indicated there were no parameters to hold Metformin.
> an order, with a start date of 5/28/2023, for regular insulin (short-acting insulin) injection per sliding scale: if BS 0-200 give 0 units; BS 201-250 give 2 units; BS 251-300 give 4 units; BS 301-350 give 6 units; BS 351-399 give 8 units, to give subcutaneously (SQ, into the fat under the skin) before meals at 6:30 am, at 11:30 am, and at 4:30 pm and at bedtime (9 pm). Notify physician if BS is less than 70 or greater than or equal to 400.
> an order, with a start date of 8/16/2023, for insulin glargine (long-acting insulin) 25 units injection SQ at bedtime (9 pm). Do not give if BS was below 100.
During a review of Resident 1 ' s Medication Administration Record (MAR), dated 8/1/2023 – 8/31/2023, the MAR indicated:
> Resident 1 ' s BS was not documented, and regular insulin injection per sliding scale was not given on 8/4/2023 at 11:30 am, on 8/11/2023 at 11:30 am, on 8/19/2023 at 4:30 pm, and on 8/19/2023 at 9 pm.
> There was no documented evidence the physician was notified about Resident 1 ' s BS level of 58 on 8/15/2023 at 11:30 am.
> Metformin 1000 mg was not administered to Resident 1 on 8/16/2023 at 6:30 am due to BS of 80, on 8/19/2023 at 4:30 pm with no BS recorded, on 8/22/2023 at 6:30 am due to BS of 80, and on 8/31/2023 at 6:30 am due to BS of 102.
During a review of Resident 1 ' s MAR, dated 9/1/2023 – 9/30/2023, the MAR indicated:
> Resident 1 ' s blood sugar was not documented, and regular insulin injection per sliding scale was not given on 9/20/2023 at 11:30 am and on 9/21/2023 at 6:30 am.
> Metformin 1000 mg was not given to Resident 1 on 9/24/2023 at 4:30 pm due to BS of 73.
> Insulin glargine 25 units injection was given with BS of 98 on 9/14/2023 at 9 pm.
During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 11/22/2022 with diagnoses which included diabetes mellitus, chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), and high blood pressure.
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for decision making was intact and she verbalized her needs. The MDS indicated Resident 2 was totally dependent on one person for bed mobility, dressing, and toilet use, and was totally dependent on two or more persons for transfers.
During a review of Resident 2 ' s current Physician Orders, for the month of October 2023, the Physician Orders indicated:
> an order, with a start date of 8/4/2023, for insulin lispro (fast-acting insulin) 10 units injection SQ three times daily at 6 am, at 2 pm, and at 10 pm.
> an order, with a start date of 8/4/2023, for insulin lispro injection per sliding scale: if BS 0-200 give 0 units; BS 201-250 give 2 units; BS 251-300 give 4 units; BS 301-350 give 6 units; BS 351-399 give 8 units, to give SQ three times daily with meals at 7 am, at 12 pm, and at 5 pm. Notify physician if BS is less than 70 or greater than 400.
> an order, with a start date of 8/4/2023, for gabapentin (nerve pain medication) 300 mg by mouth three times a day at 6 am, at 2 pm, and at 10 pm.
> an order, with a start date of 8/4/2023, for hydralazine (drug used to treat high blood pressure) 50 mg by mouth every 8 hours at 6 am, at 2 pm, and at 10 pm. Do not give if systolic blood pressure (SBP, top number of blood pressure reading) is less than 110.
> an order, with a start date of 9/19/2023, for prednisone (used to treat inflammation of the airway in COPD) 10 mg by mouth with breakfast at 7:30 am for three days.
During a review of Resident 2 ' s MAR, dated 8/1/2023 – 8/31/2023, the MAR indicated:
> Insulin lispro 10 units injection was not given on 8/20/2023 at 2 pm, and on 8/22/2023 at 2 pm.
> Resident 2 ' s blood sugar was not documented and insulin lispro injection per sliding scale was not given on 8/18/2023 at 7 am and on 8/22/2023 at 12 pm.
> Gabapentin 300 mg was not given on 8/19/2023 at 2 pm, on 8/20/2023 at 2 pm, and on 8/22/2023 at 2 pm.
> Resident 2 ' s blood pressure was not documented, and hydralazine 50 mg was not given on 8/19/2023 at 2 pm and on 8/22/2023 at 2 pm.
During a review of Resident 2 ' s MAR, dated 9/1/2023 – 9/30/2023, the MAR indicated:
> Insulin lispro 10 units injection was not given on 9/1/2023 at 2 pm.
> Gabapentin 300 mg was not given on 9/1/2023 at 2pm.
> Prednisone 10 mg was not given on 9/20/2023 at 7:30 am.
> Resident 2 ' s blood pressure was not documented, and hydralazine 50 mg was not given on 9/1/2023 at 2pm.
During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 10/2/2023 at 4:10 pm, LVN 2 checked Resident 1 ' s BS. LVN 2 stated she will not give Resident 1 metformin 1000 mg because Resident 1 ' s BS level was 87.
During a concurrent interview and record review with the Director of Quality Improvement (DQI) on 10/3/2023 at 2:15 pm, the DQI reviewed Resident 1 ' s August 2023 MAR. The DQI stated there were missing initials and BS level on the MAR.
During an interview with the Administrator (ADM), the Assistant Administrator (AADM), the Director of Nursing (DON), and the DQI on 10/3/2023 at 3:13 pm, the ADM stated she was just informed licensed nurses were not documenting on the MAR according to the facility ' s policy and procedure. The ADM stated she would investigate what was going on, would provide in-service, and include it as a project for the Quality Assurance and Performance Improvement (QAPI) committee.
During a concurrent interview and record review with the DON on 10/3/20 at 4:15 pm, the DON reviewed Resident 1 ' s Physician ' s Orders, Resident 1 ' s August 2023 MAR, and Resident 1 ' s September 2023 MAR. The DON stated licensed nurses should record the resident ' s BS level in the MAR and must give medications according to the physician ' s orders. The DON stated licensed nurses should notify the physician whenever medications were not administered to the resident. The DON stated licensed nurses must follow the parameters on when to notify the physician according to the physician ' s orders.
During a concurrent interview and record review with LVN 2 on 10/3/2023 at 4:45 pm, LVN 2 stated, on 9/14/2023 at 9 pm, she gave Resident 1 insulin glargine 25 units injection per Resident 1 ' s request, even when Resident 1 ' s BS level was only 98. LVN 2 stated she should have held the insulin glargine on 9/14/2023 at 9 pm according to the physician ' s orders.
During a phone interview with LVN 3 on 10/4/2023 at 10:15 am, LVN 3 stated on 9/18/2023 at 9 pm and on 9/29/2023 at 9 pm, she did not give insulin glargine to Resident 1 because Resident 1 ' s BS level was under 100. LVN 3 stated she knew the physician ' s order for Resident 1 was to hold the insulin glargine for BS level under 100. LVN 3 stated she always gave Resident 1 metformin 1000 mg because there was no parameter to hold metformin 1000 mg. LVN 3 stated it was important to document accurately on the resident ' s clinical record so that any medical provider who would review the resident ' s record would have knowledge of what was going on with the resident.
During a phone interview with Resident 1 ' s Primary Physician (MD 1) on 10/4/2023 at 1:13 pm, MD 1 stated whenever he wanted to know about Resident 1 ' s BS level, he usually asked the licensed nurses. MD 1 stated it was important to document the resident ' s BS level in the clinical record so he could evaluate the resident ' s BS level trend and adjust the resident ' s medications if he needed to.
During a concurrent interview and record review with the DQI on 10/4/2023 at 2:13 pm, the DQI reviewed the August 2023 and September 2023 MARs for Resident 1 and Resident 2. The DQI stated she audited the August 2023 and September 2023 MARs for Resident 1 and Resident 2 and found missing signatures or initials, missing blood pressure (BP) reading, and missing BS level on the MARs. The DQI stated she documented N and signed her initials on those dates with missing initials, missing BP reading, and missing BS level on Resident 1 ' s and Resident 2 ' s MARs and she notified the residents ' physician. The DQI stated she did not know if those medications with missing initials were not given to the residents. The DQI stated she documented on Resident 1 ' s and on Resident 2 ' s clinical records when she notified their physician regarding the missing information on the MARs but was unable to find documentation of physician notification in the clinical records.
During a concurrent interview and record review with the DQI on 10/4/2023 at 2:41 pm, the DQI reviewed the August 2023 and September 2023 MARs for Resident 1 and Resident 2. The DQI stated licensed nurses were supposed to initial the MAR right after they gave the resident their medications. The DQI stated when a resident refused to take a medication and/or when a medication was not given to the resident, the licensed nurses had to notify the physician. The DQI stated medications must be given according to the physician ' s orders and should not be held without a physician ' s order. The DQI stated BS level for insulin sliding scale should be documented in the MAR. The DQI stated it was important to check and document the resident ' s BS level in the resident ' s record so the licensed nurse would know what to do and how much insulin to give the resident per the sliding scale. The DQI stated the only record the physicians look at to determine the resident ' s trend in BS level was the MAR.
During a review of the facility ' s P&P titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame .Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .The following information is checked/verified for each resident prior to administering medications: allergies to medications and vital signs, if necessary .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose, the individual administering the medication initials the resident ' s MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident ' s medical record the date and time the medication was administered, the dosage, the route of administration, the injection site (if applicable), any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed, and the signature and title of the person administering the drug.
During a review of the facility ' s P&P titled, Obtaining a Fingerstick Glucose Level, dated October 2011, the P&P indicated the person performing the fingerstick should record the date and time the procedure was performed, the name and title of the individual(s) who performed the procedure .the blood sugar results, the nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages), and the signature and title of the person recording the data.
Aug 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 a toileting schedule on 7/31/2023 based on R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a toileting schedule on 7/31/2023 based on Resident 1's care plan for, At Risk for Fall Related to Diagnosis of Status-Post Cerebral Vascular Accident (CVA- stroke; disruption of blood flow to the brain) and Bladder Functions: Always Incontinent for one of two sampled residents (Resident 1).
This deficient practice placed Resident 1 at risk for urinary tract infection.
Cross Reference: F690
Findings:
1. During a review of Resident 1's Face Sheet (admission record), the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including right hemiplegia (paralysis of one side of the body) following cerebral infarct (stroke- disruption of blood flow to the brain), lack of coordination (uncoordinated movement) and aphasia (disorder that affects how one communicates).
During a review of Resident 1's Bowel and Bladder Assessment and Interventions (BBAI), dated 7/28/2023, the BBAI indicated if a toileting schedule was implemented, to indicate what the toileting schedule was, and to address bedtime schedule and plan during the night if appropriate. The BBAI indicated if a toileting schedule was initiated, add to the plan of care. The BBAI indicated to implement toileting schedules to maintain continence, record schedules in the care plan, care guide, or Activities of Daily Living (ADL) records; toileting program may include habit training, scheduled voiding or prompting voiding. The BBAI indicated, add to the plan of care.
During a review of Resident 1's care plan titled, At Risk for Falls Related to Diagnosis of Status-Post CVA, dated 7/31/2023, the care plan interventions indicated to implement a toileting schedule for Resident 1.
During a review of Resident 1's care plan titled, Bladder Functions: Always Incontinent, dated 7/31/2023, the care plan indicated Resident 1 would be free from complications associated with incontinence (lack of control over urination) and the care plan interventions included to assess Resident 1's bowel and bladder habits and establish a toileting schedule for Resident 1.
During a review of Resident 1's ADL Flow Sheet dated 8/1/2023 to 8/23/2023, the ADL Flow Sheet did not indicate a toileting schedule for Resident 1.
During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 8/3/2023, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, supervision (oversight, encouragement, or cueing) with eating, extensive assistance (resident involved activity, staff provide weight-bearing support) with transfers, walking, locomotion, dressing, and personal hygiene and totally dependent with toilet use (full staff performance).
During an interview on 8/23/2023 at 3:03 pm with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated CNA 1 was not aware Resident 1 had a toileting schedule. CNA 1 stated if residents (in general) had toileting schedule, CNAs are required to fill out a toileting schedule form given by the resident's nurse.
During an interview on 8/23/2023 at 4:09 pm with CNA 2, CNA 2 stated CNA 2 did not know Resident 1 had a toileting schedule.
During a concurrent interview and record review on 8/23/2023 at 4:16 pm, with the MDS Nurse (MDSN), the MDSN reviewed Resident 1's plan of care and stated Resident 1 did not have a toileting schedule in Resident 1's medical record. The MDSN stated since Resident 1's care plan indicated to establish a toileting schedule on 7/31/2023, there should have been an order and specific toileting schedule created for Resident 1 on 7/31/2023. The MDSN stated based on the BBAI, staff should create a toileting schedule for Resident 1 and the schedule should be in Resident 1's medical record.
During an interview on 8/24/2023 at 1:38 pm, with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated if Resident 1 had a toileting schedule, the CNAs needed to be document and follow Resident 1's toileting schedule in Resident 1's medical record. RNS 1 stated, RNS 1 was unaware if Resident 1 had a toileting schedule or where the documentation for the toileting schedule was. RNS 1 stated if staff were not following Resident 1's toileting schedule, Resident 1 could potentially develop a urinary tract infection.
During an interview on 8/24/2023 at 1:58 pm, with CNA 3, CNA 3 stated CNA 3 was not aware Resident 1 had a toileting schedule because it was not communicated to CNA 3.
During an interview on 8/24/2023 at 4:02 pm, with the Director of Staffing Development (DSD), the DSD stated when a resident (in general) had a toileting schedule, staff needed to document toileting every two hours a toileting schedule form or in the Treatment Administration Record (TAR). The DSD stated a toileting schedule was used to help residents train their bladder to prevent incontinence. The DSD stated if staff were not following a toileting schedule and/or documenting the toileting attempts, residents could develop a urinary tract infection. The DSD stated before 8/22/2023 there was no documented toileting schedule in Resident 1's medical records.
During an interview on 8/24/2023 at 4:11 pm, with the Director of Nursing (DON), the DON stated the DON did not know Resident 1 had a toileting schedule or what the toileting schedule was. The DON stated the DON could not confirm if staff were following any toileting schedule for Resident 1 because there was no documentation in Resident 1's medical record from 7/28/2023 to 8/21/2023 regarding toileting schedule. The DON stated staff needed to document toileting schedules on Resident 1's ADL Flow Sheet in the comment section. The DON stated since Resident 1 had interventions of toileting schedule in Resident 1's care plans initiated on 7/31/2023, then an order for toileting schedule and a toileting schedule should have been implemented on 7/31/2023.
During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. The P&P indicated the care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment, and care plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant decision making.
During a review of the facility's P&P titled, Behavioral Programs and Toileting for Urinary Incontinence, revised 10/2010, the P&P indicated guidelines for the initiation and monitoring of behavioral interventions and/or a toileting plan for residents with incontinence. The Toileting Plans indicated staff will provide scheduled toileting, prompted voiding, or other interventions to manage incontinence. The P&P indicated habit training/scheduled voiding was a technique that called for scheduled toileting at regular intervals on a planned basis to match a resident's voiding habits. The Documentation indicated staff will document the results of behavioral/toileting trial in a resident's medical records.
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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accuracy of medical records for one of two sampled residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accuracy of medical records for one of two sampled residents (Resident 1) by failing to:
1. Complete a Fall Risk Assessment (FRA) for Resident 1 upon admission to the facility on 7/28/2023, in accordance with the facility's Policy and Procedure on Fall Risk Assessment.
2. Complete an accurate FRAs for Resident 1 on 8/22/2023 and 8/23/2023.
These deficient practices had the potential for Resident 1 to not receive the appropriate care and interventions needed to prevent a fall.
Findings:
1. During a review of Resident 1's Face Sheet (admission record), the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including right hemiplegia (paralysis of one side of the body) following cerebral infarct (stroke- disruption of blood flow to the brain), lack of coordination (uncoordinated movement) and aphasia (disorder that affects how one communicates).
During a review of Resident 1's admission Nursing Assessment, dated 7/28/2023, the admission Nursing Assessment indicated there was no FRA completed on 7/28/2023.
During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 8/3/2023, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, supervision (oversight, encouragement, or cueing) with eating, extensive assistance (resident involved activity, staff provide weight-bearing support) with transfers, walking, locomotion, dressing, and personal hygiene and totally dependent with toilet use (full staff performance).
During a concurrent interview and record review on 8/23/2023 at 4:16 pm, with the MDS Nurse (MDSN), the MDSN reviewed Resident 1's FRA dated 8/22/2023 and FRA, dated 8/23/223. MDSN stated there was no FRA completed for Resident 1 before 8/22/2023. The MDSN stated Resident 1's FRA completed on 8/22/2023 indicated Resident 1 was at high risk for falls. The MDSN stated another FRA was completed for Resident 1 on 8/23/2023 that indicated Resident 1 was at moderate risk for falls. The MDSN stated the FRA dated 8/23/2023 indicated the FRA assessment reason was admission. The MDSN stated every resident needed a fall risk assessment upon admission to the facility as part of the admission assessment.
During an interview on 8/23/2023 at 5:18 pm, with the Director of Nursing (DON), the DON stated an FRA needed to be completed on admission to the facility for every resident, so staff knew what nursing interventions needed for the safety of each resident. The DON stated Resident 1's FRA was not completed on admission on [DATE]. The DON stated the facility could have implemented interventions for Resident 1 before Resident 1's fall on 8/22/2023.
During an interview on 8/24/2023 at 1:38 pm, with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated a fall risk assessment needed to be completed upon resident's (in general) admission to the facility. RNS 1 stated the FRA was part of the admission process. RNS 1 stated the FRA was done for each resident's safety. RNS 1 stated the FRA was used to determine what nursing interventions the facility needed to prevent a resident from falling at the facility. RNS 1 stated it was possible the facility could have placed other interventions to the resident's fall on 8/22/2023 had the FRA been done upon Resident 1's admission to the facility on 7/28/2023.
2. During a review of Resident 1's FRA, dated 8/22/2023, the FRA indicated Resident 1 was at high risk for falls. The FRA did not indicate a reason for the assessment.
During a review of Resident 1's FRA, dated 8/23/2023, the FRA indicated Resident 1 was at moderate risk for falls. The FRA indicated the reason for the assessment was admission.
During a concurrent interview and record review on 8/23/2023 at 4:16 pm, with the MDSN, the MDSN reviewed Resident 1's FRA dated 8/22/2023 and 8/23/2023. MDSN stated there was no FRA completed for Resident 1 before 8/22/2023. The MDSN stated Resident 1's FRA score on 8/22/2023 indicated Resident 1 was at high risk for falls. The MDSN stated Resident 1's FRA score on 8/23/2023 indicated Resident 1 was at moderate risk for falls. The MDSN stated the MDSN was not sure why Resident 1's FRA score went from being a high risk for falls to a moderate risk for falls, one day after the resident had a fall incident on 8/22/2023. The MDSN stated the FRAs dated 8/22/2023 and 8/23/2023 were inconsistent, and that Resident 1's FRA score should have stayed the same or gone up after Resident 1's fall on 8/22/2023.
During an interview on 8/23/2023 at 5:18 pm, with the DON, the DON stated Resident 1's FRAs completed on 8/22/2023 and 8/23/2023 (one day apart), were not accurate because the scores were significantly different. The DON stated the two FRAs were confusing to the staff and could potentially cause Resident 1 to not receive the necessary interventions and treatment.
During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment, revised 3/2018, the P&P indicated nursing staff, attending physician, consultant pharmacist, therapy staff, and others would seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant information. The P&P indicated, upon admission, the nursing staff and physician will review a resident's record for history of falls, especially in the last 90 days and recurrent or periodic bouts of falling over time, and that assessment data would be used to identify underlying medical conditions that could increase the risk of injury from falls.
During a review of the facility's P&P titled, Charting and Documentation, revised 7/2017, the P&P indicated all documentation in the medical record would be objective, complete, and accurate.
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement toileting schedule for one of two sampled re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement toileting schedule for one of two sampled residents (Resident 1), based on Resident 1's Bowel and Bladder Assessment and Interventions (BBAI), dated 7/28/2023.
This deficient practice placed Resident 1 at risk for urinary tract infection (UTI- infection that affects part of the urinary tract).
Cross Reference: F656
Findings:
During a review of Resident 1's Face Sheet (admission record), the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including right hemiplegia (paralysis of one side of the body) following cerebral infarct (stroke- disruption of blood flow to the brain), lack of coordination (uncoordinated movement) and aphasia (disorder that affects how one communicates).
During a review of Resident 1's Bowel and Bladder Assessment and Interventions (BBAI), dated 7/28/2023, the BBAI indicated Resident 1 had a frequency of voiding (urinating) higher than eight times per day. The BBAI indicated Resident 1 was alert and oriented and showed willingness. The BBAI indicated for staff to check Resident 1 frequently and change as needed; peri-care (caring for genital and rectal areas of the body) following each incontinent episode; possible use of brief or other protective barrier, or the use of external collection devices. The BBAI indicated to implement toileting schedules to maintain continence, record schedules in the care plan, care guide, or Activities of Daily Living (ADL) records; toileting program may include habit training, scheduled voiding or prompting voiding.
During a review of Resident 1's care plan titled, Bladder Functions: Always Incontinent, dated 7/31/2023, the care plan indicated Resident 1 would be free from complications associated with incontinence (lack of control over urination) and the care plan interventions included to assess Resident 1's bowel and bladder habits and establish a toileting schedule for Resident 1.
During a review of Resident 1's ADL Flow Sheet dated 8/1/2023 to 8/23/2023, the ADL Flow Sheet did not indicate toileting schedule for Resident 1.
During a review of Resident 1's Medication Administration Record (MAR), dated 8/1/2023 to 8/22/2023, the MAR indicated Resident 1 did not have a toileting schedule.
During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 8/3/2023, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, supervision (oversight, encouragement, or cueing) with eating, extensive assistance (resident involved activity, staff provide weight-bearing support) with transfers, walking, locomotion, dressing, and personal hygiene and totally dependent with toilet use (full staff performance).
During an interview on 8/23/2023 at 3:03 pm with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated CNA 1 was not aware Resident 1 had a toileting schedule. CNA 1 stated if residents (in general) had toileting schedule, CNAs are required to fill out a toileting schedule form given by the resident's nurse.
During an interview on 8/23/2023 at 4:09 pm, with CNA 2, CNA 2 stated CNA 2 did not know Resident 1 had a toileting schedule.
During a concurrent interview and record review on 8/23/2023 at 4:16 pm, with the MDS Nurse (MDSN), the MDSN reviewed Resident 1's plan of care and stated Resident 1 did not have a toileting schedule in Resident 1's medical record. The MDSN stated since Resident 1's care plan indicated to establish a toileting schedule on 7/31/2023, there should have been an order and specific toileting schedule created for Resident 1 on 7/31/2023. The MDSN stated based on the BBAI, staff should create a toileting schedule for Resident 1 and the schedule should be in Resident 1's medical record.
During an interview on 8/24/2023 at 1:38 pm, with Registered Nurse Supervisor (RNS) 1, RNS 1 stated if
During an interview on 8/24/2023 at 1:38 pm, with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated if Resident 1 had a toileting schedule, the CNAs needed to be document and follow Resident 1's toileting schedule in Resident 1's medical record. RNS 1 stated, RNS 1 was unaware if Resident 1 had a toileting schedule or where the documentation for the toileting schedule was. RNS 1 stated if staff were not following Resident 1's toileting schedule, Resident 1 could potentially develop a urinary tract infection.
During an interview on 8/24/2023 at 1:58 pm, with CNA 3, CNA 3 stated CNA 3 was not aware Resident 1 had a toileting schedule because it was not communicated to CNA 3. CNA 3 stated following a toileting schedule was important for Resident 1.
During an interview on 8/24/2023 at 2:56 pm, with Responsible Party 1 (RP 1), RP 1 stated when RP 1 visited Resident 1, RP 1 would stay for two to three hours at a time. RP 1 stated whenever RP 1 was visiting Resident 1 at the facility, staff did not ask if Resident 1 needed to use the restroom and was not aware Resident 1 was supposed to have a toileting schedule.
During an interview on 8/24/2023 at 3:01 pm, with RP 2, RP 2 stated, when visiting Resident 1, staff did not come to Resident 1's room to ask if Resident 1 needed to use the restroom or try to get Resident 1 up to the toilet. RP 2 stated RP 2 usually visited RP 2 for two to three hours at a time.
During an interview on 8/24/2023 at 4:02 pm, with the Director of Staffing Development (DSD), the DSD stated when a resident (in general) had a toileting schedule, staff needed to document toileting every two hours on a toileting schedule form or in the Treatment Administration Record (TAR). The DSD stated a toileting schedule was used to help residents train their bladder to prevent incontinence. The DSD stated if staff were not following a toileting schedule and/or documenting the toileting attempts, residents could develop a urinary tract infection.
During an interview on 8/24/2023 at 4:11 pm, with the Director of Nursing (DON), the DON stated the DON did not know Resident 1 had a toileting schedule or what the toileting schedule was. The DON stated the DON could not confirm if staff were following any toileting schedule for Resident 1 because there was no documentation in Resident 1's medical record from 7/28/2023 to 8/21/2023 regarding toileting schedule. The DON stated staff needed to document toileting schedules on Resident 1's ADL Flow Sheet in the comment section. The DON stated since Resident 1 had interventions of toileting schedule in Resident 1's care plans initiated on 7/31/2023, an order for toileting schedule needed to be obtained from Resident 1's physician and a toileting schedule should have been implemented on 7/31/2023.
During a review of the facility's P&P titled, Behavioral Programs and Toileting for Urinary Incontinence, revised 10/20210, the P&P indicated guidelines for the initiation and monitoring of behavioral interventions and/or a toileting plan for residents with incontinence. The Toileting Plans indicated staff will provide scheduled toileting, prompted voiding, or other interventions to manage incontinence. The Documentation indicated staff will document the results of behavioral/toileting trial in a resident's medical records.
Aug 2023
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Release of Informat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Release of Information by not providing a copy of medical records within the policy ' s time frame for one of three sampled residents' (Resident 10) representative.
This failure resulted in Resident 10 ' s Representative 1 ' s (R 1) right being violated when the facility did not provide access to Resident 10 ' s medical record from dates [DATE] to [DATE] (total 6 days).
Findings:
During a review of Resident 10 ' s Face Sheet, indicated Resident 10 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (MS, decreased nerve function with initial inflammation of the protective myelin nerve covering) and chronic kidney disease (gradual loss of kidney function over several years). The Face Sheet indicated Resident 10 was self-responsible.
During a review of Resident 10 ' s Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated [DATE], indicated Resident 10 did not have an impairment in cognition (mental action or process of acquiring knowledge and information). The MDS indicated Resident 10 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 was totally dependent on staff with transfers, and locomotion on and off the unit.
During a review of a Discharge Summary from a General Acute Care Hospital 1 (GACH 1), dated [DATE] indicated Resident 10 expired on [DATE].
During a review of the facility ' s document titled, Disclosure Log 2023, (list of requests for medical records the facility had received) indicated R 1 had requested for a copy of Resident 10 ' s medical records on [DATE].
During an interview on [DATE] at 2:37 pm, R 1 stated R 1 still had not received any medical records from the facility. R 1 also stated the facility had not contacted R 1 regarding the medical records requested.
During an interview on [DATE] at 3:14 pm, Medical Records Assistant (MRA) stated MRA received FM 1 ' s request for the release of Resident 10 ' s medical records on [DATE]. MRA stated MRA was not able to contact R 1 because MRA was busy and was working alone.
During a concurrent interview and record review on [DATE] at 4:01 pm, with the Director of Medical Records (DMR), Resident 10 ' s Face Sheet was reviewed. DMR stated R 1 was listed on Resident 10 ' s Face Sheet. DMR stated if a resident expired, only a family member listed of the resident ' s Face Sheet would be able to receive copies of the resident ' s medical records so R 1 should have received the medical records within the time frame.
A review of the facility ' s policy and procedure titled, Release of Information, revised [DATE], indicated the resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative (sponsor). A resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident ' s written or oral request. A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain the integrity of the dialysis access site during bathing for one of three sampled dialysis residents (Resident 1) by...
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Based on observation, interview, and record review, the facility failed to maintain the integrity of the dialysis access site during bathing for one of three sampled dialysis residents (Resident 1) by failing to keep it clean and dry.
This failure had the potential to increase Resident 1 ' s risks for infection.
Findings:
During a review of Resident 1 ' s Face Sheet, indicated the facility initially admitted Resident 1 on 7/14/2023 with multiple diagnoses including end-stage renal disease (irreversible and permanent kidney impairment) with dependence on renal hemodialysis (renal dialysis, process of purifying the blood of a patient whose kidneys failed to function normally), and type 2 diabetes mellitus (chronic condition wherein the body does not produce enough insulin or resists insulin, causing abnormal blood sugar).
During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 7/20/2023, indicated Resident 1 did not have an impairment in cognition (mental action or process of acquiring knowledge and information). The MDS indicated Resident 1 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 was totally dependent on staff with transfers, walking, and locomotion off unit. The MDS indicated Resident 1 required physical help in part of bathing activity.
During a review of Resident 1 ' s care plan, titled Patient Care Plan: Renal Dialysis, dated 7/2023, indicated Resident 1 ' s dialysis access site was located on Resident 1 ' s right upper chest. The care plan indicated approaches/plan included coordinating care with the dialysis center, but it did not include the interventions for a hemodialysis central venous catheter (HD – CVC, dialysis access site wherein a long, flexible tube is inserted via a small incision on the skin over the selected vein located in the neck, upper chest, or groin and into a large vein) to address care during bathing and/or showering.
During a review of Resident 1 ' s Physician Orders for 8/2023, indicated Resident 1 was ordered hemodialysis at Dialysis Center 1 (DC 1) every Mondays, Wednesdays, and Fridays on 7/14/23.
During an interview on 8/14/2023 at 11:02 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 went to DC 1 for his hemodialysis. CNA 1 stated when assisting Resident 1 with showers, she would cover the dialysis access site with a dry towel. CNA 1 stated she would not use the trash can liners/plastic bag due to the difficulty of securing it on the resident ' s skin during bathing.
During a concurrent observation and interview on 8/15/2023 at 12:49 p.m. with Licensed Vocational Nurse 1 (LVN 1) and Resident 1 in Resident 1 ' s room, Resident 1 ' s HD-CVC was covered with a gauze and a transparent film dressing with an opening at the bottom for the HD-CVC tubing. The HD-CVC tubing and its ports were observed covered with a wet gauze dressing. Resident 1 stated CNA 1 assisted him with his shower in the morning. Resident 1 stated CNA 1 covered his HD-CVC with plastic, but Resident 1 stated his HD-CVC still got wet. LVN 1 stated the wet gauze dressing indicate water could get inside the dialysis access site and increase Resident 1 ' s risk for infection.
During an interview on 8/15/2023 at 4 p.m. with the Director of Nursing (DON), DON stated a HD-CVC must not be wet due to risks for infection. The DON stated if a dialysis resident (in general) requested for a shower, the staff must use a plastic bag to cover the HD-CVC, secure the plastic bag on the skin with a tape, and add a towel over the plastic bag, if desired, for an extra layer of protection to prevent water or moisture from entering the dialysis access site. The DON stated aiming the shower head directly on the HD-CVC must be avoided.
During a review of the facility ' s policy and procedures, titled Hemodialysis Access Care, dated 9/2010, indicated the following:
1. The central catheter must be kept clean and dry at all times. Bathing and showering are not permitted with this device.
2. Those caring for the catheter site must wear a mask and gloves when doing so. Dressing changes, if ordered, should be done using sterile technique.
3. Never pull or tug on the catheter. Do not use scissors near the catheter.
4. Dialysis catheters must be marked for dialysis use only so they are not confused with central venous access devices.
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 F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 6) who w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 6) who was diagnosed with dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities) received appropriate recreational activities based off the facility ' s policy and procedure (P&P) titled, Dementia- Clinical Protocol.
This failure had the potential for Resident 6 to develop further cognitive decline and isolation.
Cross Reference: F676
Findings:
During a review of Resident 6 ' s Face Sheet, indicated Resident 6 was admitted to the facility on [DATE]. Resident 6 ' s diagnoses included dementia and retinal edema (buildup of fluid in the macula, an area at the back of the eye causing blurry vision).
During a review of Resident 6 ' s MDS (MDS- a standardized resident assessment and care screening tool) dated 7/6/2023, indicated Resident 6 ' s primary language was Chinese. The MDS indicated Resident 6 had severely impaired cognition. Resident 6 required limited assistance with bed mobility. Resident 6 required extensive assistance with transfers, walking, dressing, and personal hygiene. Resident 6 was totally dependent (full staff performance every time during entire 7-day period) with locomotion and toilet use.
During an observation on 8/14/2023 at 11:37 am, of Resident 6, Resident 6 was observed sitting in a wheelchair in the activities room. Facility staff were observed using hand gestures to communicate with Resident 6, but Resident 6 did not respond to staff. Staff were observed speaking Spanish and English in the activities room.
During an interview on 8/14/2023 at 11:43 am, with CNA 4, CNA 4 stated Resident 6 did not speak English, but spoke Chinese. CNA 4 stated CNA 4 did not know how to communicate with Resident 6 because Resident 6 had dementia and Resident 6 ' s primary language was Chinese. CNA 4 stated staff did not use a translator or any communication assistance to communicate with Resident 6.
During an observation on 8/14/2023 from 11:45 am to 12 pm, of Resident 6, Resident 6 was observed in the activities room. Staff were initially observed not engaging in communication and activities with Resident 6. Staff were observed speaking Spanish and English in the activities room. Staff were observed engaging with other residents on saying words that started with the letter S. The activity was translated in Spanish by staff. Staff were then observed speaking in slow, loud English to Resident 6, and used hand gestures to communicate with Resident 6. Resident 6 was observed not responding to the hand gestures or slow, loud English.
During an interview on 8/14/2023 at 12:01 pm, with the Activities Assistant (AA), the AA stated the AA tried to communicate verbally in English to residents who did not speak either English or Spanish and used hand signs/gestures but could not provide an example. The AA stated the AA and other staff who assisted with activities did not use communication assistance when communicating with resident who spoke Chinese during activities. The AA stated the AA thought Resident 6 understood the AA because Resident 6 would nod Resident 6 ' s head. The AA stated the AA could not confirm if the head nod meant Resident 6 understood the AA. The AA stated Resident 6 came to the activities room but did not participate because the facility did not have activities in Chinese.
During an interview on 8/14/2023 at 1:33 pm, with the Director of Staffing Development (DSD), DSD stated Residents who have dementia already have difficulty expressing themselves with language, and a language barrier could make expressing themselves worse. This could potentially lead to a cognitive decline for Residents 6.
During an interview on 8/14/2023 at 4:07 pm, with the Director of Nursing (DON), the DON stated Resident 6 was diagnosed with dementia. The DON stated Resident 6 had the potential for cognitive decline if staff did not communicate with Resident 6 in Resident 6 ' s primary language.
During a review of the facility ' s policy and procedure (P&P) titled, Dementia- Clinical Protocol, revised 11/2018, the P&P indicated staff and physicians would review current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual ' s condition, related complications, and functional abilities and impairments. The treatment/management of the P&P indicated direct care staff will support the resident in initiating and completing activities and tasks of daily living including bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised supported throughout the day as needed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility staff failed to ensure the availability of clean bed and bath linens at designated times in three of six sampled linen closets (Closets...
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Based on observation, interview, and record review, the facility staff failed to ensure the availability of clean bed and bath linens at designated times in three of six sampled linen closets (Closets 4N, 4S, and 6S).
This failure had the potential to cause a decline in the residents' psychosocial and physical well-being due to inadequate linens available for use to ensure a homelike, sanitary environment for the residents.
Findings:
During an interview on 8/14/2023 at 11:58 a.m., Certified Nursing Assistant 3 (CNA 3) stated there was a shortage of linens-towels, wash cloth, underpads (absorbent material used in nursing facilities to tend incontinence issues), blankets, and pillowcases-especially in the morning. CNA 3 stated the facility used to provide wet/dry wipes to be used when providing incontinence care to residents, but CNAs currently use towels and wash cloths to clean the residents.
During a concurrent observation and interview on 8/14/2023 at 12:17 p.m. with CNA 3, the sampled linen closets in Stations 4, 5, and 6 were inspected. CNA 3 stated the following:
1. In Closet 4N, there was one blanket, two fitted sheets, no flat sheets, three pillowcases, three wash cloths, nine towels, no underpads, and no wet/dry wipes.
2. In Closet 4S, there were three blankets, five fitted sheets, one pillowcase, four flat sheets, three wash cloths, 11 towels, and two underpads.
3. In Closet 6S, there were no towels, wash cloths, or wet-dry wipes.
During an observation on 8/14/2023 at 2:50 p.m. with Maintenance and Laundry Supervisor (MLS), the following were noted:
1. In Closet 4N, there were no washcloths, no fitted sheets, no flat sheets, no underpads, no wet/dry wipes, but had approximately five towels, three blankets, and three pillowcases.
2. In Closet 4S, there was one blanket, one towel, approximately four wash cloths, one box of adult dry-wipe cloth, but no pillowcases or underpads.
3. In Closet 6S, there were no towels, wash cloths, wet/dry wipes, or pillowcases, but had seven underpads and one blanket.
During an observation and interview on 8/15/2023 at 12:34 p.m., Resident 1 was sitting in his wheelchair in his room. Resident 1 was alert and oriented and able to communicate his needs to the staff. Resident 1 stated he had requested a blanket or a pillowcase from the CNA (in general) in the past, the CNA had told him they (blanket or pillowcase) were not available.
During a concurrent interview and record review on 8/15/2023 at 1:55 p.m. with the Housekeeping/Maintenance Supervisor (HMDS), the linen delivery/distribution protocols were reviewed. HMDS stated the following:
1. Per closet in Stations 4, 5, and 6 (each station has 2 closets), 50 towels, 50 wash cloths, 25 underpads, 15 bath blankets, 20 fitted sheets, and 20 flat sheets would be delivered during scheduled delivery times.
2. The linen delivery times for Stations 4, 5, and 6 would be as follow: 8:15 a.m. to 8:30 a.m., 11:30 a.m., 2:45 p.m. to 3 p.m., 6:30 p.m. to 7 p.m. and 9 p.m. to 10 p.m.
During an interview on 8/15/2023 at 2:25 p.m., Laundry Staff 2 (LS 2) stated she would start her shift at 1 p.m. and end at 8:30 p.m. LS 2 stated she would deliver a set of linens to Stations 4, 5, and 6 at 1:30 p.m. and 6 p.m. LS 2 stated she would put in each closet in Stations 4, 5, and 6, 40 towels, 50 wash cloths, 25 underpads, six bath blankets, 15 pillowcases, six fitted sheets, 25 flat sheets, and three blankets.
During another interview on 8/15/2023 at 3:28 p.m., HMDS stated the laundry staff might have some delays in the linen delivery at times, but there was no linen shortage in the facility. HMDS stated some CNAs throw away towels after use, instead of placing them in the dirty laundry hamper to be washed with bleach. HMDS stated she was aware that CNAs were using wet/dry wipes to clean the residents and/or provide incontinence care to the residents, but she was not responsible for ordering those supplies. HMDS stated hoarded stacks of linens in resident room closets were found during random inspection of resident room closets.
During an interview on 8/16/2023 at 11:24 a.m., LS 1 stated she would start her shift at 5:30 a.m. and end at 1 p.m. LS 1 stated she would deliver the first set of linens to Stations 4, 5, and 6 starting at 8 a.m. and would refill the linen closets at 12 p.m. LS 1 stated she would put 60 towels, 30 underpads, 25 wash cloths, 10 bath blankets, 25 fitted sheets, 25 flat sheets, and 10 blankets. LS 1 stated if she did not have enough linens from the freshly laundered linens, she would come back and deliver the missing linens at a later time after washing.
During an interview on 8/16/2023 at 12:13 p.m., CNA 5 stated the unit would sometimes have linen shortages, depending on who the laundry staff were scheduled to deliver the linens to the stations. CNA 5 stated a particular laundry staff (unnamed) would deliver linens all the time, but other laundry staff would be late and would tell us, It's still going and drying. CNA 5 stated if there were no bedsheets, he would not change the residents' bedsheet unless visibly dirty. CNA 5 stated dry/wet wipes were better for use with cleaning the residents as they were less rough and thrown away after use and towels were conserved for other purposes.
During an interview on 8/16/2023 at 12:35 p.m., CNA 6 stated, Sometimes we don't have linens until 10 a.m. CNA 6 stated she would have the extra work on top of a busy workload to go to the laundry room to find linen for the residents.
During an interview on 8/16/2023 at 1:09 p.m., the Central Supply Manager (CSM) stated wipes were on a backorder from the supplier. CSM stated there was one incident when he brought out a case of wet/dry wipes, but it was gone the next day. CSM stated a few months ago, he was instructed to stop ordering wet/dry wipes, but he was instructed to order wet/dry wipes again shortly after due to the linen shortage.
During an interview on 8/16/2023 at 2:31 p.m. with the Administrator and the Director of Nursing (DON), Admin stated they were not informed of any linen shortage in the facility. Administrator stated they would look into the problems to ensure adequate linens were delivered to each station to maintain a sanitary environment and allow CNAs to provide good quality of care.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of two sampled residents (Residents 5 and 6...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of two sampled residents (Residents 5 and 6) who had limited English proficiency (LEP) receive translation support and services provided by the facility according to the facility's policy and procedure (P&P) titled, Translation and/or Interpretation of Facility Services, by failing to:
1. Provide a communication board and/or oral interpretation of Residents 5 and 6's primary languages of Mandarin (dialect of Chinese) and Cantonese (dialect of Chinese), respectively.
2. Not rely on family members and friends to provide interpretation services for Residents' Five and Six and produce written consent for disclosure of protected health information.
These failures had the potential for Residents 5 and 6 not being able to communicate their basic needs in their primary languages and had the potential for Residents 5 and 6 to suffer cognitive (ability to think, remember, and reason) decline.
Findings:
1. During a review of Resident 5's Face Sheet, indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included fracture of the lower end of the right radius (broken wrist bone) and disorder of bone density and structure (bone disease that develops when bone mineral density and bone mass decreases, which could lead an increase the risk of broken bones).
During a review of Resident 5's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 7/19/2023, the MDS indicated Resident 5 needed or wanted an interpreter to communicate with a doctor or health care staff. The MDS indicated Resident 5 had severely impaired cognition (ability to think and process information). The MDS indicated Resident 5 required supervision with bed mobility, transfers, walking, locomotion, and eating. Resident 5 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with dressing, toilet use, and personal hygiene.
During a review of Resident 6's Face Sheet, indicated Resident 6 was admitted to the facility on [DATE]. Resident 6 diagnoses included dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities) and retinal edema (buildup of fluid in the macula, an area at the back of the eye causing blurry vision).
During a review of Resident 6's MDS dated [DATE], indicated Resident 6's primary language was Chinese. The MDS indicated Resident 6 had severely impaired cognition. Resident 6 required limited assistance with bed mobility. Resident 6 required extensive assistance with transfers, walking, dressing, and personal hygiene. Resident 6 was totally dependent (full staff performance every time during entire 7-day period) with locomotion and toilet use.
During an interview on 8/10/2023 at 3:42 pm, with Responsible Party (RP) 1, RP 1 stated Resident 5's primary language was Mandarin. RP 1 stated RP 1 had never seen staff use a communication board or use a translation service with Resident 5. RP 1 stated facility staff were not able to carry on a conversation with Resident 5 because Resident 5 did not speak enough English. RP 1 stated Resident 5 understood Mandarin because Mandarin was Resident 5's birth language. RP 1 stated RP 1, Wished there was more Mandarin communication and activities for Resident 5 at the facility.
During an interview on 8/10/2023 at 4:10 pm, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 5's English was limited.
During a concurrent observation and interview on 8/14/2023 at 11:24 am, with Certified Nurse Assistant (CNA) 4, in Resident 5's room, CNA 4 was observed speaking to Resident 5 in English. CNA 4 asked Resident 5, Good? Resident 5 was observed nodding her head. CNA 4 stated CNA 4 was asking if Resident 5 Was good or okay, or if Resident 5 needed anything. CNA 4 stated CNA 4 could not be sure Resident 5 understood CNA 4's question. CNA 4 stated CNA 4 spoke English when communicating with Resident 5. CNA 4 stated CNA 4's English was not good. CNA 4 stated facility staff did not use a communication board or translator when speaking to Resident 5. CNA 4 stated CNA 4 used hand gestures or English to communicate with Resident 5, but that CNA 4 could be sure Resident 5 understood.
During an observation on 8/14/2023 at 11:37 am, of Resident 6, Resident 6 was observed sitting in a wheelchair in the activities room. Facility staff were observed using hand gestures to communicate with Resident 6, but Resident 6 did not respond to staff. Staff were observed speaking Spanish and English in the activities room.
During an interview on 8/14/2023 at 11:43 am, with CNA 4, CNA 4 stated Resident 6 did not speak English, but spoke Chinese. CNA 4 stated CNA 4 did not know how to communicate with Resident 6 because Resident 6 had dementia and Resident 6's primary language was Chinese. CNA 4 stated staff did not use a communication board, translator, or any other communication assistance to communicate with Resident 6.
During an observation on 8/14/2023 from 11:45 am to 12 pm, of Resident 6, Resident 6 was observed in the activities room. Staff were observed not engaging in communication with Resident 6. Staff were observed speaking Spanish and English in the activities room. Staff were observed engaging with other residents on saying words that started with the letter S. The activity was not translated in any other language other than Spanish by staff. Staff were observed speaking in slow, loud English to Resident 6, and were using hand gestures to communicate with Resident 6. Resident 6 was observed not responding to the hand gestures or slow, loud English.
During an interview on 8/14/2023 at 12:01 pm, with the Activities Assistant (AA), the AA stated the AA tried to communicate verbally in English to residents who did not speak either English or Spanish and used hand signs/gestures but could not provide an example. The AA stated the AA and other staff who assisted with activities did not use communication assistance when communicating with resident who spoke Chinese during activities. The AA stated the AA thought Resident 6 understood the AA because Resident 6 would nod Resident 6's head. The AA stated the AA could not confirm if the head nod meant Resident 6 understood the AA. The AA stated Resident 6 came to the activities room but did not participate because the facility did not have activities in Chinese.
During an interview on 8/14/2023 at 12:19 pm, with LVN 2, LVN 2 stated LVN 2 did not use a communication board or translator for Resident 6. LVN 2 stated the facility did not provide any services for translating for residents who spoke any dialect of Chinese. LVN 2 stated staff will use their personal phones to translate for Resident 6 but did not think it was the facility's protocol to do so. LVN 2 stated no staff on Resident 5 and 6's unit spoke any dialect of Chinese. LVN 2 stated the communication board was a tool to communicate with LEP residents.
During an interview on 8/14/2023 at 1:33 pm, with the Director of Staffing Development (DSD), the DSD stated Resident 6's primary language was Mandarin. The DSD stated the DSD was not sure what Resident 5's primary language was but was not English. DSD stated Resident 5 and Resident 6, Could feel awkward and not feel understood, or understand the care being provided to Residents 5 and 6. This could make them feel bad as humans. The DSD stated, Residents who have dementia already have difficulty expressing themselves with language, and a language barrier could make expressing themselves worse. This could potentially lead to a cognitive decline for Residents 5 and 6. The DSD stated the facility could be doing more interventions for residents who speak Chinese. The DSD stated the communication board was the most effective way to communicate with Residents 5 and 6 should be used every time staff communicate with Residents 5 and 6 and should be in Residents 5 and 6's rooms at all times.
During an interview on 8/14/2023 at 2:27 pm, with the DSD, the DSD stated both Residents 5 and 6 would be considered to have LEP.
During an interview on 8/14/2023 at 2:40 pm, with the Social Services Director (SSD), the SSD stated Resident 5's primary language could be Mandarin Chinese but stated Resident 5's primary language was not English. The SSD stated Resident 6's primary language could be Mandarin but stated Resident 6's primary language was not English. The SSD stated it was not acceptable for staff to use hand gestures to communicate with residents who were LEP. The SSD stated there was a translation service staff could call to communicate with residents who were LEP but was not sure if staff were aware that service was available to them.
During an interview on 8/14/2023 at 4:07 pm, with the Director of Nursing (DON), the DON stated on 8/4/2023, the DON interviewed Resident 5 in English, but Resident 5 could not understand the DON. The DON stated Resident 5 should have been interviewed in Mandarin to communicate effectively with her. The DON stated during that interview the DON got the communication board to use with Resident 5, however the communication board was not effective. The DON stated she could not communicate with Resident 5. The DON stated staff should not be using hand gestures or speak English to communicate with Residents 5 and 6, or any other residents who had LEP. The DON stated this is because they might not be getting the right care. The DON stated this could make Residents 5 and 6 feel bad and depressed. The DON stated not communicating with Residents 5 and 6 in their correct primary language could potentially cause cognitive decline. The DON stated staff should be reporting to charge nurses if they are not able to effectively communicate with residents who have LEP so the issue can go up the chain-of-command (hierarchy of order) to the SSD.
2. During an interview on 8/10/2023 at 3:42 pm, with RP 1, RP 1 stated RP 1 did not remember receiving or signing a consent or documentation indicating RP 1 would translate between the facility staff and Resident 5.
During a concurrent interview and record review on 8/14/2023 at 2:40 pm, with the SSD, the SSD reviewed the P&P titled, Translation and/or Interpretation of Facility Services. The SSD stated, according to the P&P, Family members and friends shall not be relied upon to provide interpretation services for residents unless explicitly requested by the resident. If any family or friends are used to interpret, the resident must provide written disclosure of protected health information (PHI). The SSD stated the SSD was not sure if Residents 5 and 6 had this consent in their medical records.
During an interview on 8/14/2023 at 4:07 pm, with the DON, the DON stated Residents 5 and 6 did not have documentation in their medical records indicating consent of written disclosure of PHI. The DON stated there was no other documentation in Residents 5 and 6's medical records indicating consent to have family or friends provide translation when staff needed to communicate with Residents 5 or 6.
During a review of the facility's P&P titled, Translation and/or Interpretation of Facility Services, revised 5/2017, the P&P indicated the facility's language access program will ensure that individuals with LEP shall have meaningful access to information and services provided by the facility. The policy interpretation and implementation indicated, when encountering LEP individuals, staff members would conduct the initial language assessment and notify the staff person in charge of the language assess program, all LEP persons should receive a written notice in their primary language of their rights to obtain competent oral translation services free of charge- if written notice was not possible, such notice would be given orally. The P&P indicated family members and friends shall not be relied upon to provide interpretation services for the resident unless explicitly requested by the resident. If family or friends are used to interpret, the resident must provide written consent for disclosure of PHI. The P&P indicated it was understood in order provide meaningful access to services provided by the facility, translation and/or interpretation must be provided in a way that was culturally relevant and appropriate to the LEP individual. The P&P indicated staff shall be trained upon hire and at least annually on how to provide language assess services to LEP residents.
During a review of the facility's P&P titled, Resident Rights, Revised 12/2016, the P&P indicated employees shall treat all resident with kindness, respect, and dignity. The policy interpretation and implementation indicated federal and state laws guaranteed certain basic rights to all residents in the facility, and those rights included resident's right to: a dignified existence and communication with and access to people and services, both inside and outside of the facility.
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 follow their policy and procedure (P&P) titled, Pressure Injury Ris...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Pressure Injury Risk Assessment to ensure skin assessment was conducted for one of three sampled residents (Resident 10).
This failure had the potential for Resident 10 to be at risk for worsening skin condition and/or pressure injury.
Findings:
During a review of Resident 10's Face Sheet, the Face Sheet indicated Resident 10 was admitted to the facility on [DATE]. Resident 10's diagnoses included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), enterocolitis (inflammation in the small intestine and large intestine) due to clostridium difficile (a germ that causes diarrhea and inflammation in the intestines), and urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra).
During a review of Resident 10's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 6/16/2023, indicated Resident 10 did not have an impairment in cognition (mental action or process of acquiring knowledge and information). The MDS indicated Resident 10 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 was totally dependent on staff with transfers, and locomotion on and off the unit. The MDS indicated Resident 10 was at risk of developing pressure ulcers/injuries.
During a review of Resident 10's care plan titled, Patient Care Plan: Risk for Skin Breakdown, dated 6/9/2023, the care plan indicated Resident 10 was at risk for skin breakdown. The care plan indicated one of the approaches/plans was for staff to perform daily body checks to monitor for skin injury and skin tear while giving care.
During a review of Resident 10's Physician Orders for the month of June 2023, the Physician Orders indicated Resident 10 had an order on 6/29/2023 for treatment to excoriations (skin breakdown) on the left inner thigh and right buttock.
During a concurrent interview and record review on 8/15/2023 at 3:18 pm, with Licensed Vocational Nurse 3 (LVN 3) of Resident 10's medical records, LVN 3 stated the treatment for Resident 10's excoriations started on 6/30/2023 and ended on 7/20/2023. LVN 3 confirmed and stated there were no weekly skin assessments documented in Resident 10's medical records between 6/30/2023 to 7/20/2023. LVN 3 stated Resident 10's excoriations should have been assessed weekly.
During an interview on 8/15/2023 at 3:37 pm, the Director of Nursing (DON) stated Resident 10's weekly skin assessment should have been done. The DON stated an excoriation was considered a skin breakdown and it should have been assessed.
During a review of the facility's P&P titled, Pressure Injury Risk Assessment, revised March 2020, the P&P indicated the purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. Conduct a comprehensive skin assessment with every risk assessment.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on interviews and record review, the facility failed to ensure Certified Nursing Assistant (CNA) staffing requirements were met in accordance with the Facility Assessment, for eight of nine samp...
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Based on interviews and record review, the facility failed to ensure Certified Nursing Assistant (CNA) staffing requirements were met in accordance with the Facility Assessment, for eight of nine sampled dates 8/5/2023 to 8/11/2023 and 8/13/2023.
This failure had the potential to result in a decline in the physical and psychosocial well-being due to poor quality of care from staff burnout for residents located in Stations 4, 5, and 6.
Findings:
During an interview on 8/14/2023 at 11:02 a.m., CNA 1 stated her facility unit was always short-staffed, at least twice or thrice a week with about 11-12 residents assigned per CNA during the 7 a.m. - 3 p.m. shift (Day shift). CNA 1 stated the CNAs (in general) do not get assistance with feeding residents in their unit. CNA 1 stated residents could only be changed twice per shift-once before lunch and another time after lunch. CNA 1 stated residents (in general) must be changed and repositioned at least every 2 hours per shift. CNA 1 stated she felt she could not provide quality care.
During an interview on 8/14/2023 at 11:58 a.m., CNA 3 stated his facility unit was short-staffed about once or twice per week with about 11 residents assigned per CNA during the Day shift. CNA 3 stated CNAs (in general) could provide the care, but they do a sloppier job. CNA 3 stated, for example, he could clean the resident (in general) but could not apply the lotion due to time constraints. CNA 3 stated he would mainly focus on changing the residents' (in general) diaper, but if there was a stain on the resident's bed, he would not be able to change the bedding.
During an interview on 8/16/2023 at 12:13 p.m., CNA 5 stated he would be assigned an average of 8-10 residents during Day shift.
During an interview on 8/16/2023 at 12:35 p.m., CNA 6 stated she would be assigned an average of 10-12 residents every day during Day shift for the past week. CNA 6 stated she would usually not be able to take her breaks to ensure completion of all the resident care tasks.
During a concurrent interview and record review on 8/16/2023 at 1:28 p.m. with the Director of Staff Development (DSD), the Facility Assessment was reviewed. The Facility Assessment indicated the general staffing plan to ensure the facility had sufficient staff members to meet the residents' needs at any given time was to assign eight residents to one direct care staff member (also known as the CNA) during the Day shift, 10 residents to one direct care staff member during the Evening shift, and 19 residents to one direct care staff member during the Night shift. The DSD stated she was not aware of the Facility Assessment. The DSD stated it was important to maintain the ratio of residents to direct care staff as indicated in the Facility Assessment to achieve quality of care and prevent staff burnout. The DSD stated Staffing Coordinator 1 (SC 1) was responsible for assigning CNAs to the units per shift.
During a concurrent review and interview on 8/16/2023 at 2:01 p.m. with SC 1, the CNA assignment sheets for Stations 4, 5, & 6 from 8/5/2023 through 8/13/2023 were reviewed. The CNA assignment sheets indicated the following:
1. 8/5/2023 - Station 5 Evening shift CNAs assigned to 12-13 residents, Station 6 Evening shift CNAs assigned to 12-13 residents
2. 8/6/2023 - Station 4 Day shift CNAs assigned to 10-11 residents, Station 5 Day shift CNAs assigned to 9-10 residents, Station 6 Day shift CNAs assigned to 9-10 residents
3. 8/7/2023 - Station 4 Day shift CNAs assigned to 10-11 residents, Station 6 Day shift CNAs assigned to 9-10 residents
4. 8/8/2023 - Station 4 Day shift CNAs assigned to 10-11 residents, Station 6 Day shift CNAs assigned to 9-10 residents
5. 8/9/2023 - Station 4 Day shift CNAs assigned to 9-10 residents, Station 5 Day shift CNAs assigned to 9-10 residents, Station 6 Day shift CNAs assigned to 9-10 residents
6. 8/10/2023 -Station 5 Day shift CNAs assigned to 9-10 residents, Station 6 Day shift CNAs assigned to 9-10 residents
7. 8/11/2023 - Station 5 Day shift CNAs assigned to 9-10 residents, Station 6 Day shift CNAs assigned to 9-10 residents
8. 8/13/2023 - Station 5 (2) Day shift CNAs with unclear assignment for 36 residents, Station 6 Day shift CNAs assigned to 9-10 residents
The SC 1 stated her goal was to assign 8-9 residents per CNA during the Day shift, 10-11 residents per CNA during the Evening shift, and 12-14 residents per CNA during the Night shift. SC 1 stated when the facility is not able to ensure enough CNAs per shift and per station, the residents would not get proper care or CNAs would not be able to spend as much time with the residents. SC 1 stated the facility must hire more CNAs or utilize Registry (contractual agency that would provide the facility with nursing staff based on its staffing needs) when short-staffed.
During a concurrent interview and record review on 8/16/2023 at 2:31 p.m. with the Administrator and the Director of Nursing (DON), the Facility Assessment was reviewed. The Administrator stated he has not had the chance to review the Facility Assessment since he started working in the facility a few days ago. The Administrator stated the facility has partnered with Registry agencies to fill staffing needs, if needed. The DON stated sufficient staffing was necessary to ensure that quality care would be provided to the residents.
During a review of the facility's policy and procedures, titled Staffing, dated 10/2017, it indicated the facility must provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. The policy indicated staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care.
Jul 2023
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Infection Control
(Tag F0880)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide a sanitary (clean) environment to prevent the spread of infections to one of five sampled residents (Resident 1) by f...
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Based on observation, interview, and record review, the facility failed to provide a sanitary (clean) environment to prevent the spread of infections to one of five sampled residents (Resident 1) by failing to ensure:
1. Flies from outside of the facility did not enter Resident 1's room and lay eggs behind Resident 1's left ear.
2. The fly light (insect trap that used light to attract insects/flies) in the subacute unit (area of the facility where residents with tracheostomy tubes [tube inserted into the front of the neck to help the residents breathe] reside) was powered on and plugged in the electrical outlet.
3. Certified Nursing Assistant 2 (CNA 2) cleansed Resident 1's ears during the bed bath.
These failures resulted in Certified Nursing Assistant 3 (CNA 3) finding 5 maggots (small, wormlike, larvae [immature and wingless forms of an insect that hatch from the eggs] of a fly) behind Resident 1's left ear on 7/25/2023, at 8 pm.
Cross Reference: F925
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 12/21/2016, and readmitted Resident 1 on 3/16/2023. The admission Record indicated Resident 1's diagnoses included respiratory failure (when the lungs cannot get enough oxygen into the blood or remove carbon dioxide [waste gas made in the body's cells] from the blood), dependence on ventilator (machine used to deliver breaths to a person who is unable to breathe on their own), and functional quadriplegia (complete inability to move due to severe disability or weakness caused by another medical condition without injury or damage to the spinal cord). The admission Record indicated Resident 1 had a tracheostomy tube.
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/7/2023, the MDS indicated Resident 1 had severely impaired cognitive (ability to think and reason) skills for decision making. The MDS indicated Resident 1 was non-verbal and was totally dependent on three or more persons for bed mobility, dressing, eating, toileting, bathing, and personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, washing/drying face, and hands).
During a review of Resident 1's Situation, Background, Appearance/Evaluation, Review/Notify (SBAR, a standardized communication tool between healthcare providers) Communication form, dated 7/26/2023, timed 12:46 am, the SBAR Communication form indicated on 7/25/2023, at 8 pm, maggots were noted along the hairline behind Resident 1's left ear.
During a review of Resident 1's Nurses' Note, dated 7/26/2023, at 9:50 pm, the Nurses' Note signed by the Director of Clinical Operations (DCO) indicated on 7/25/2023, at 8 pm, while providing care to Resident 1, CNA 3 found five maggots along Resident 1's hairline behind Resident 1's left ear. The Nurses' Note indicated CNA 3 notified Registered Nurse Supervisor 1 (RNS 1) immediately, and RNS 1 checked Resident 1's skin and noted redness (size not indicated) behind Resident 1's left ear (where the maggots were found).
During a review of Resident 1's Care Plan, dated 7/27/2023, the Care Plan indicated Resident 1 had maggots and non-blanchable redness (redness of the skin that did not turn white when pressed) along the hairline behind Resident 1's left ear. The Care Plan indicated the nursing interventions included: to clean behind Resident 1's left ear with soap and water and apply triple antibiotic ointment (medication used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns) every day, and as needed for seven days. The nursing interventions included to ensure windows and doors were always closed; to ask the wound care consultant to evaluate the area behind Resident 1's left ear; to monitor the area behind Resident 1's left ear for increased redness, tenderness, and pain; and to notify Resident 1's Medical Doctor (MD 1) for any changes.
During an interview on 7/27/2023, at 2:52 pm, with the DCO, the DCO stated on 7/25/2023, at 8:09 pm, RNS 1 notified the DCO that CNA 3 found maggots along the hairline behind Resident 1's left ear. The DCO stated Resident 1's left ear was reddish raw. The DCO stated MD 1 ordered to wash the reddish raw area (behind Resident 1's left ear) with soap and water, apply triple antibiotic ointment, and cover the reddish raw area with gauze dressing. The DCO stated she spoke with CNA 2, who took care of Resident 1 during the morning shift on 7/25/2023, from 7 am to 3 pm, and CNA 2 told the DCO she gave Resident 1 a bed bath on 7/25/2023, (untimed), but she did not clean behind Resident 1's ears. The DCO stated RNS 3 (another RNS/morning shift RNS) told the DCO that she saw some flies in the subacute unit on 7/25/2023.
During an observation on 7/27/2023, at 3:12 pm, in Nursing Station 2 (located in the subacute unit), the fly light located in the hallway was turned off.
During a concurrent observation and interview on 7/27/2023, at 3:15 pm, with Licensed Vocational Nurse 1 (LVN 1), in Nursing Station 2, LVN 1 stated she saw one fly last Monday (7/24/2023) in the subacute unit's hallway, and she killed the fly with a towel. LVN 1 stated when she came to work today (7/27/2023), LVN 1 brought her own fly swatter. LVN 1 took the fly swatter out of the medication cart and stated she had not used the fly swatter yet. LVN 1 stated, when LVN 1 killed the fly with the towel, LVN 1 informed the RNS (unidentified). LVN 1 stated the subacute unit exit door was located at the end of the hallway and used as an emergency exit. LVN 1 stated the flies flew inside the facility whenever the emergency exit door was opened. LVN 1 stated the facility's dumpster (a large metal container for holding trash) was located right outside the emergency exit door in the back of Nursing Station 2. LVN 1 stated it was important not to have flies inside the facility especially in the subacute unit because residents (in general) in this unit had tracheostomies (an incision in the windpipe made to relieve an obstruction to breathing and flies flew inside the residents' mouth. LVN 1 stated residents (in general) in the subacute unit could not move and LVN 1 worried the residents might get maggots.
During a concurrent observation and interview on 7/27/2023, at 3:28 pm, with LVN 2, in Nursing Station 2, LVN 2 stated the fly light was turned off (time unknow). LVN 2 unplugged the computer located on top of the medication cart from the electrical outlet and plugged the fly light in the same electrical outlet. LVN 2 stated Nurses (unidentified) unplugged the fly light so they could charge the computer. LVN 2 stated it was important for the fly light to stay on so that flies did not fly inside the residents' (in general) rooms.
During an interview on 7/27/2023, at 3:44 pm, with Resident 2, Resident 2 stated she would occasionally (unable to recall dates and times) see flies in the facility, especially during mealtime.
During a concurrent observation and interview on 7/27/2023, at 3:57 pm, with LVN 4, at Resident 1's bedside, Resident 1's left ear had a dark reddish-brown scab (dry, rough skin formed over a cut or wound during healing) and redness above the left ear canal (a small, tube-like pathway that extends from the outer ear to the eardrum [separates outer ear from middle ear]). Resident 1 also had red open areas behind the left ear that extended to Resident 1's hairline. LVN 4 stated it was important to not have flies in the subacute unit because some residents in the subacute unit were not able to swat the flies. LVN 4 stated You don't want maggots on the residents.
During an interview on 7/27/2023, at 4:09 pm, with Resident 4, in the subacute unit, Resident 4 stated, Once in a while, I see a fly here.
During an interview on 7/27/2023, at 4:13 pm, with Resident 5, in the subacute unit, Resident 5 stated, Two days ago, I saw a fly here in the room.
During an interview on 7/27/2023, at 4:17 pm, with RNS 2, RNS 2 stated it was important to keep the fly light on to prevent flies from landing and laying eggs on the residents.
During an interview on 7/27/2023, at 4:27 pm, with the Housekeeping Supervisor (HKS), the HKS stated it was important to keep the fly light on to deter and catch flies. The HKS stated doors needed to be kept closed to prevent flies from entering the facility.
During a review of the facility's Final Investigation Report, dated 7/28/2023, the Investigation Report indicated on 7/25/2023, at 8 pm, CNA 3 informed RNS 1 that Resident 1 had five small maggots behind her left ear. The Investigation Report indicated LVN 5 saw a few flies in the hallways in the subacute unit on 7/25/2023, and RNS 3 (another RNS) instructed LVN 5 to ensure the flies did not fly inside Resident 1's and other residents' rooms. The Investigation Report indicated the Respiratory Therapist (RT, a medical professional who care for persons with breathing problems) noticed flies on 7/25/2023.
During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated 5/2008, the P&P indicated, the facility needed to ensure that the building was kept free of insects and rodents.
During a review of P&P titled, Shower/Tub Bath, dated October 2010, the P&P indicated for nursing staff to promote cleanliness and provide comfort and to observe the condition of the residents' skin.
During a review of the Centers for Disease Control and Prevention's (the national public health agency of the United States) Guidelines for Environmental Infection Control in Health-Care Facilities, updated in July 2019, the Guidelines indicated, Insects can serve as agents for the mechanical transmission of microorganisms (organisms visible only under a microscope, i.e. bacteria, virus, or fungus), or as active participants in the disease transmission process by serving as a vector (an agent that carries and transmits an infectious pathogen [disease-causing microorganism] into another living organism). The Guidelines indicated closing doors to the outside can help with pest control. Insects should be kept out of all areas of the health-care facility.
[Source: https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html]
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 14 rooms in the dementia unit (area of the facility for residents with lo...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 14 rooms in the dementia unit (area of the facility for residents with loss of memory, language, problem-solving and other thinking reside), and 3 of 23 rooms in the subacute unit (area of the facility where residents with tracheostomy tubes [tube inserted into the front of the neck to help the residents breathe] reside).
These failures resulted in flies flew inside Resident 1's, 2's, 4's and 5's rooms, and layed eggs on Resident 1's left ear.
Cross reference: F880
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 12/21/2016, and readmitted Resident 1 on 3/16/2023. The admission Record indicated Resident 1's diagnoses included respiratory failure (when the lungs cannot get enough oxygen into the blood or remove carbon dioxide [waste gas made in the body's cells] from the blood), dependence on ventilator (machine used to deliver breaths to a person who is unable to breathe on their own), and functional quadriplegia (complete inability to move due to severe disability or weakness caused by another medical condition without injury or damage to the spinal cord). The admission Record indicated Resident 1 had a tracheostomy tube.
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/7/2023, the MDS indicated Resident 1 had severely impaired cognitive (ability to think and reason) skills for decision making. The MDS indicated Resident 1 was non-verbal and was totally dependent on three or more persons for bed mobility, dressing, eating, toileting, bathing, and personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, washing/drying face, and hands).
During a review of Resident 1's Situation, Background, Appearance/Evaluation, Review/Notify (SBAR, a standardized communication tool between healthcare providers) Communication form, dated 7/26/2023, timed 12:46 am, the SBAR Communication form indicated on 7/25/2023, at 8 pm, maggots were noted along the hairline behind Resident 1's left ear.
During a review of Resident 1's Nurses' Note, dated 7/26/2023, at 9:50 pm, the Nurses' Note signed by the Director of Clinical Operations (DCO) indicated on 7/25/2023, at 8 pm, while providing care to Resident 1, CNA 3 found five maggots along Resident 1's hairline behind Resident 1's left ear. The Nurses' Note indicated CNA 3 notified Registered Nurse Supervisor 1 (RNS 1) immediately, and RNS 1 checked Resident 1's skin and noted redness (size not indicated) behind Resident 1's left ear (where the maggots were found).
During an observation on 7/27/2023, at 3:12 pm, in Nursing Station 2 (located in the subacute unit), the fly light located in the hallway was turned off.
During a concurrent observation and interview on 7/27/2023, at 3:15 pm, with Licensed Vocational Nurse 1 (LVN 1), in Nursing Station 2, LVN 1 stated she saw one fly last Monday (7/24/2023) in the subacute unit's hallway, and she killed the fly with a towel. LVN 1 stated when she came to work today (7/27/2023), LVN 1 brought her own fly swatter. LVN 1 took the fly swatter out of the medication cart and stated she had not used the fly swatter yet. LVN 1 stated, when LVN 1 killed the fly with the towel, LVN 1 informed the RNS (unidentified). LVN 1 stated the subacute unit exit door was located at the end of the hallway and used as an emergency exit. LVN 1 stated the flies flew inside the facility whenever the emergency exit door was opened. LVN 1 stated the facility's dumpster (a large metal container for holding trash) was located right outside the emergency exit door in the back of Nursing Station 2.
During a concurrent observation and interview on 7/27/2023, at 3:28 pm, with LVN 2, in Nursing Station 2, LVN 2 stated the fly light was turned off. LVN 2 unplugged the computer located on top of the medication cart from the electrical outlet and plugged the fly light in the same electrical outlet. LVN 2 stated Nurses (unidentified) unplugged the fly light so they could charge the computer. LVN 2 stated it was important for the fly light to stay on so that flies did not fly inside the residents' rooms.
During an interview on 7/27/2023, at 3:44 pm, with Resident 2, Resident 2 stated she would occasionally (unable to recall dates and times) see flies in the facility, especially during mealtime.
During an interview on 7/27/2023, at 4:09 pm, with Resident 4, in the subacute unit, Resident 4 stated, Once in a while, I see a fly here.
During an interview on 7/27/2023, at 4:13 pm, with Resident 5, in the subacute unit, Resident 5 stated, Two days ago, I saw a fly here in the room.
During an interview on 7/27/2023, at 4:17 pm, with RNS 2, RNS 2 stated it was important to keep the fly light on to prevent flies from landing and laying eggs on the residents.
During an interview on 7/27/2023, at 4:27 pm, with the Housekeeping Supervisor (HKS), the HKS stated it was important to keep the fly light on to deter and catch flies. The HKS stated windows and doors needed to be kept closed to prevent flies from entering the facility.
During a review of the facility ' s policy and procedure (P&P) titled, Pest Control, dated 5/2008, the P&P indicated, the facility needed to ensure that the building was kept free of insects and rodents.
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
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 1) was allowed to retu...
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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 1) was allowed to return to the facility to the first available bed. Resident 1 was transferred to a General Acute Care Hospital (GACH) on [DATE] and resident ' s bed hold expired on [DATE]. On [DATE], Resident 1 was ready to return to the facility and was not allowed to return.
This had the potential for the resident to not receive required care and services that was provided by the facility before resident was transferred to the hospital.
Findings:
During a review of Resident 1's Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), dependence on respirator/ventilator (a bedside breathing machine with tubes that connect to the resident's airways), and unspecified atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). The Face Sheet also indicated Resident 1 was discharge on [DATE] with a return to the facility anticipated.
During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], indicated Resident 1 had an unclear speech and rarely or never had the ability to make self-understood and understand others. The MDS indicated Resident 1 ' s cognitive skills for daily decision making were severely impaired and resident was totally dependent on staff for most of her activities for daily living (ADL) such as bed mobility, transfer to and from bed, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene.
During a review of Resident 1's Situation Background Appearance Request (SBAR, facility ' s communication and progress note for changes in condition) form dated [DATE], completed at 2:37 PM, indicated that facility received a call from the dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) center where Resident 1 was having dialysis treatment, that Resident 1 was sent to a GACH emergency room (ER).
During a review of the Resident 1's Nurses Notes, dated [DATE] at 10:28 AM, indicated that facility received a call from the dialysis center where Resident 1 was having her dialysis treatment, that Resident 1 was sent to a GACH ER due to possible low hemoglobin (Hgb, the protein in the blood that carries oxygen throughout the body), and resident was diaphoretic (excessive sweating due to an underlying health condition or a medication).
During an interview with the facility's admission Director (AD) on [DATE] at 11:40 AM, she stated, she verified Resident 1 ' s insurance coverage after she was made aware that Resident 1 was ready to be readmitted to the facility. The AD stated, after verifying Resident 1 was no longer enrolled with the LA County Medical, she spoke with Resident 1 ' s case manager at the GACH, on [DATE], and told her she will clarify with the facility's Administrator (ADM) if Resident 1 could be readmitted . The AD stated, verification of coverage was done for all admissions to make sure facility can provide services needed by the resident.
During an interview with the facility's ADM on [DATE] at 12:45 PM, the ADM stated, that Resident 1 was transferred to the GACH on [DATE] and Resident 1 ' s bed hold expired on [DATE]. The ADM stated, on [DATE], before the bed hold expired, the GACH ' s case manager called the facility to inquire about Resident 1 ' s bed. Resident 1's bed was still available and on [DATE]. The GACH ' s case manager told them Resident 1 was on IV (intravenous medication administration route) of heparin (an anticoagulant) and was ready to come back to the facility. The ADM stated, they told the GACH ' s case manager that they need to postpone the readmission because they do not do IV heparin administration in the facility. The ADM stated, the GACH called them again on [DATE] and told them that Resident 1 was no longer on IV heparin and is ready to come back. Facility verified Resident 1 ' s LA County Medical eligibility on [DATE] before readmitting resident so they can arrange for dialysis transportation and found out family disenrolled resident from LA Care (LA County Medical) when she was at the GACH and changed it to San [NAME] County Medical. The ADM stated, this change in coverage mean that coverage for dialysis transportation would no longer be covered by LA County Medical because resident now belongs to San [NAME] County Medical and San [NAME] Medical would not cover for dialysis transportation if resident is staying in an LA County facility. On 5/12, 2023, the ADM spoke to the GACH ' s Social Services Director (SSD) to tell her what to do to get back dialysis transportation coverage for the resident so they can readmit the resident. The ADM stated, the Resident 1 was welcome to come back here anytime, regardless of the insurance status, once there is a clean female ' s bed available in the Subacute Unit. The ADM stated, currently they did not have any clean bed available in the Subacute Unit for the resident. The ADM stated, she already notified the AD that Resident 1 was a priority for readmission on the first available clean bed. The ADM stated, currently the facility has one female bed available for resident with C. auris (Candida auris, a type of multi-drug resistant yeast/fungus that can cause severe infection in hospital or nursing home residents) because roommate was on isolation for C. auris, and another female bed was available for a resident with C. auris and C. diff (Clostridioides difficile, a bacteria that causes diarrhea and colitis or inflammation of the colon) because roommate is on isolation for C. auris and C. diff infection.
During an interview with the facility ' s Social Services Director (SSD) on [DATE] at 1:20 PM, the SSD stated, on [DATE] she called the Ombudsman for Medical enrollment and on behalf of Resident 1 applied for LA County Medical coverage. The SSD stated, the application was approved, and coverage will start on [DATE]. The SSD stated, Resident 1 ' s family was aware and agreed to the enrollment.
During a review of the facility ' s daily census for the Sub-Acute Unit and the facility ' s daily List of Residents on Isolation from [DATE] to [DATE], indicated when the facility refused to readmit Resident 1, the following clean beds were available in the Sub-Acute Unit:
1. On [DATE], room [ROOM NUMBER] A was vacant and was a clean bed because 114 B was occupied by Resident 2, a female resident who was not on isolation;
2. On [DATE], room [ROOM NUMBER] B was vacant and was a clean bed because 205 A was occupied by Resident 3, a female resident who was not on isolation;
3. On [DATE], room [ROOM NUMBER] A was vacant and was a clean bed because 114 B was occupied by Resident 2, a female resident who was not on isolation;
4. On [DATE], both room [ROOM NUMBER] A and room [ROOM NUMBER] B were vacant, no isolation;
5. On [DATE], both room [ROOM NUMBER] A and room [ROOM NUMBER] B were vacant, no isolation;
6. On [DATE], both room [ROOM NUMBER] A and room [ROOM NUMBER] B were vacant, no isolation;
7. On [DATE], room [ROOM NUMBER] A was vacant and was a clean bed because 114 B was occupied by Resident 4, a female resident who was not on isolation;
8. On [DATE], both room [ROOM NUMBER] A and room [ROOM NUMBER] B were vacant, no isolation;
9. On [DATE], both room [ROOM NUMBER] A and room [ROOM NUMBER] B were vacant, no isolation.
During a review of the facility ' s policy and procedure titled, admission & Readmission, revised in [DATE], indicated residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. The facility ' s implementation of the policy indicated that a Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed if the resident:
a) Requires the services provided by the facility;
b) Meets the admission criteria as outlined in the facility policy;
c) Was not discharged for any reason outlined in the Transfer or Discharge Notice policy;
d) Is eligible for Nursing Medicaid services.
The facility ' s implementation of the policy also indicated that residents who are not receiving Medicaid benefits will be readmitted to the facility upon the first availability of a bed if the resident:
a) Needs care and medical treatment that can be provided by the facility;
b) Was not discharged for non-payment of services; and
c) Was not discharged because of behavior problems.
May 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 change the tubing and humidifier (devices that releas...
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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 change the tubing and humidifier (devices that release water vapor or steam to increase moisture levels) water bottle for oxygen (O2) treatment once a week for three of three sampled residents (Residents 2, 3, and 4) as indicated in the facility's policy titled Changing/Cleaning of Disposable and Non-Disposable Equipment.
This deficient practice had the potential for Residents 2, 3 and 4 to be at risk for infection and/or complication in using the same oxygen tubing and humidifier bottle for too long.
Findings:
1. During a review of Resident 2's Facesheet (admission record) indicated the facility admitted the resident on 4/25/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD- disease that causes obstructed airflow from the lungs), diabetes mellitus (high blood sugar), asthma (a condition in which the tubes that carry air in and out of the lungs narrow and swell causing reversible obstruction).
During a review of Resident 2's Physician's Order Sheet, dated 4/25/2023, the Physician's Order Sheet indicated for Resident 2 to receive continuous Oxygen (O2) at 3 liters per minute (LPM-unit of volume metric), may titrate fraction of inspired oxygen (FiO2, is the concentration of oxygen in the gas mixture) to keep O2 saturation (measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) above 92%.
During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/4/2023, the MDS indicated Resident 2 was cognitively intact (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses). The MDS indicated Resident 2 required extensive assistance from staff for transfer, walking, dressing, toilet use. The MDS indicated Resident 2 required total dependence (full staff performance every time) from staff for personal hygiene.
2. During a review of Resident 3's Facesheet indicated the facility admitted Resident 3 on 12/21/2022 with diagnoses that included encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition such as viral infection or toxins in the blood), persistent vegetative state, dysphagia (difficulty swallowing).
During a review of Resident 3's Physician's Telephone Order dated 12/21/2022, the Physician's Telephone Order indicated for Resident 3 to receive continuous Oxygen (O2) at 2-3 LPM via T-bar (T-shaped tubing use to deliver oxygen therapy).
During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had severe impaired cognition. The MDS indicated Resident 3 required total dependence (full staff performance every time) from staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene.
3. During a Review of Resident 4's Facesheet indicated the facility admitted Resident 4 on 3/11/2023 with diagnoses that included traumatic brain injury (an injury as result of a violent blow or jolt to the head), diabetes mellitus (high blood sugar), Gastro-Esophageal Reflux Disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining), nontraumatic intracerebral hemorrhage (bleeding into the brain tissue).
During a review of Resident 4's Physician's Telephone Order, dated 3/11/2023, the Physician's Telephone Order indicated for the resident to have continuous Oxygen (O2) at 2-3 LPM via T-bar (T-shaped tubing use to deliver oxygen therapy).
During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had severe impaired cognition. The MDS indicated Resident 3 required total dependence (full staff performance every time) from staff for bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
During an observation and interview on 5/17/2023, at 8:10 AM, with the Infection Prevention Nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), the IPN stated, the oxygen tubing for Resident 2 was dated as 5/8/2023 (more than one week). IPN stated it was important to change the oxygen tubing weekly to prevent infection.
During an observation and interview on 5/17/2023, at 8:40 AM, with IPN, the IPN stated, the oxygen tubing for Residents 3 and 4's humidifier bottles dated 5/6/2023 (more than one week). The IPN stated it was important to change the humidifier bottle weekly to prevent infection.
During an interview on 5/17/2023, at 10:40 AM, with the Respiratory Therapist 1 (RT1), RT 1 stated, the RT was responsible for changing the oxygen tubing and humidifier bottles on the subacute unit and nursing would change the tubing in the Skill Nursing Facility (SNF) unit. RT 1 stated, it was very important to change the resident equipment ' s according to policy and guideline to minimize the chance of infection.
During an interview on 5/17/2023, at 11:25 AM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, for the SNF unit, the oxygen tubing needed to be changed every week on Sunday night by the night shift charge nurse or supervisor. LVN 1 stated, it was very important to change the oxygen tubing according to the policy because if the resident had the oxygen tubing too long that might cause respiratory infection which can harm the resident.
During a review the facility's policy and procedure titled, Changing/Cleaning of Disposable and Non-Disposable Equipment, with a revised dateof 12/1/2019, indicated, To minimize the risk of infection. The policy and procedure indicated, Disposable equipment is for single patient use only and will be change as regularly scheduled and on a PRN basis. Oxygen tubing and humidifier are to be change once a week on Saturday and PRN.
Apr 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the activities of daily living (ADL, basic ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the activities of daily living (ADL, basic self-care tasks which includes bathing or showering, dressing, personal hygiene, getting in and out of bed or a chair, walking, using the toilet, and eating) care plan for two of three sampled residents (Residents 1 and 3).
1. For Resident 1, the facility failed to provide hand hygiene (cleaning hands) and fingernail trimming.
2. For Residents 1 and 2, the facility failed to ensure the call lights (a device used by a resident to signal their need for assistance from staff) were within reach and in good working condition.
These deficient practices had the potential for Residents1 and 3 not to receive assistance with ADLs.
Findings:
1. A review of Resident 1 ' s Face Sheet (admission record) indicated the facility admitted Resident 1 on 10/21/2022 with diagnosis of rheumatoid arthritis (disorder that causes pain and inflammation of the joints).
A review of Resident 1 ' s ADL care plan, dated 10/27/2022, indicated Resident 1 required assistance with ADL due to impaired physical mobility and generalized weakness. The care plan goals were to increase ADL independence, to be groomed daily, and to meet Resident 1 ' s ADL needs daily. The care plan interventions included to encourage independence, assist Resident 1 with ADL as needed, monitor Resident 1 for ADL needs, have thecall light within Resident 1 ' s reach and for the staff to answer the call light promptly.
A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/5/2023, indicated Resident 1 ' s cognitive (ability to think and reason) skills for decision making was intact. The MDS indicated Resident 1 was totally dependent on staff to move around in bed, to move to or from bed, chair, wheelchair, or standing position, to dress, to eat, to use the toilet, and to maintain personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, washing/drying face, and hands).
2. A review of Resident 3 ' s Face Sheet indicated the facility admitted Resident 3 on 2/15/2011 and readmitted the resident on 5/6/2021 with diagnosis of hemiplegia (paralysis or severe or complete loss of feeling and movement in the arm, leg, and sometimes face on one side of the body) following cerebral infarction (stroke, damage to tissues in the brain which occurs because of disrupted blood flow to the brain) affecting left nondominant side (paralysis of the left arm and left leg of a right-handed individual).
A review of Resident 3 ' s ADL care plan, dated 9/2/2022, indicated Resident 3 required assistance with ADL due to left hemiplegia. The care plan goals were to increase ADL independence, to maintain ADL function, to be groomed daily, and to meet Resident 3 ' s ADL needs daily. The care plan interventions included to encourage independence, assist Resident 3with ADL as needed, monitor the resident for ADL needs, have the call light within the resident ' s reach, and for the staff to answer thecall light promptly.
A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 had moderately impaired cognitive skills for decision making, had impaired movement of his left arm and left leg, had a colostomy (surgically created hole in the abdomen to allow feces to leave the body and into a bag), and was totally dependent on staff to move to or from bed, chair, wheelchair, or standing position, to move to and from different locations in the facility, to dress, to use the toilet, and to maintain personal hygiene. The MDS indicated Resident 3 required extensive assistance from staff to move around in bed and required limited assistance from staff to eat.
During a concurrent observation and interview with Resident 3 on 4/20/2023 at 1:07 pm, Resident 3 was observed sitting up in bed eating lunch using his right hand. Resident 3 ' s right hand had brown, foul-smelling matter on it and his right-hand fingernails were long with dark brown, foul-smelling matter underneath the fingernails. When the surveyor asked Resident 3 about the brown matter on his right hand and under his fingernails, Resident 3 pointed to his colostomy bag and stated, That ' s from this.
During a concurrent observation and interview on 4/20/2023 at 1:15 pm, the Unit Manager (UM) stated Certified Nursing Assistants (CNAs) needed to provide nail care with ADL care daily and as needed. The UM looked at Resident 3 ' s right hand and fingernails and said, They (CNAs) need to clean his hands and cut his nails.
During an interview on 4/20/2023 at 3:54 pm, the Director of Staff Development (DSD) stated the residents ' (in general) hands, nails, and oral care were part of daily ADL care and provided as needed. The DSD stated when serving meals to the resident, staff (CNAs) needed to clean the resident ' s hands and offer hand sanitizer towelettes.
During an interview on 4/26/2023 at 2:20 pm, the Director of Nursing (DON) stated nail care and hand hygiene were part of the residents ' (in general) ADL care every shift.
A review of the facility ' s policy and procedure titled, Assisting the Resident with In-Room Meals, dated 12/2013, indicated, Be sure the resident is prepared to receive the meal (i.e., offered bedpan or urinal, face and hands washed, hair combed, etc.) before placing the tray on the resident ' s overbed table.
A review of the facility ' s policy and procedure titled, Handwashing/Hand Hygiene, dated 8/2019, indicated the facility considers hand hygiene (cleaning hands by either washing them with soap and water, or by using a hand sanitizer) the primary means to prevent the spread of infections. The policy indicated to perform hand hygiene before and after eating or handling food.
A review of the facility ' s policy and procedure titled, Care of Fingernails/Toenails, dated 2/2018, indicated, The purposes of the procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The policy indicated, Nail care includes daily cleaning and regular trimming.
2. During an observation on 4/18/2023 at 2:22 pm, inside Resident 3 ' s room, Resident 3 was heard calling out for a staff and Resident 1 was observed in bed. Resident 1 ' s call light button was on the floor, with the call light cord clipped to the top of Resident 1 ' s mattress. The call light button was out of Resident 1 ' s reach. Resident 3 was observed in bed and was asked to turn on his call light to call for assistance. Resident 3 looked around his bed for his call light and stated he did not have a call light button. Resident 3 ' s call light button was clipped to the call light cord coming out of the call light reset panel on the wall. The call light button was out of Resident 3 ' s reach.
During a concurrent observation and interview with the UM on 4/18/2023 at 2:25 pm, the UM went inside Resident 3 ' s room and told Resident 3 she would get a staff to assist him. When asked about Resident 3 ' s call light, the UM looked around the room and found Resident 3 ' s call light button clipped to the call light cord coming out of the call light reset panel on the wall. The UM unclipped the call light button from the cord on the wall and handed it to Resident 3. The UM saw Resident 1 ' s call light button on the floor, picked it up from the floor, and put the call light button on Resident 1 ' s bed. The UM did not adjust the length of Resident 1 ' s call light cord which was clipped to the top of Resident 1 ' s mattress, and the call light button remained out of Resident 1 ' s reach. The UM stated call lights needed to always be within the resident ' s reach.
During an observation on 4/18/2023 at 2:40 pm, CNA 1 and CNA 2 repositioned Resident 1 in bed. After repositioning Resident 1, CNA 2 placed Resident 1 ' s call light button closer to the resident but the call light cord was too short to reach Resident 1. CNA 2 adjusted the length of the call light cord that was clipped to Resident 1 ' s mattress so the call light button would be within Resident 1 ' s reach. CNA 2 handed Resident 1 the call light button and asked Resident 1 to turn on his call light. CNA 2 looked at Resident 1 ' s call light button and said, It ' s broken. Upon close inspection of Resident 1 ' s call light, the button to turn on Resident 1 ' s call light was missing and there was no other way for Resident 1 to activate his call light. CNA 2 stated she wouldlet the Maintenance Staff (MS) know Resident 1 ' s call light needed to be replaced.
During an observation on 4/18/2023 at 2:47 pm, Licensed Vocational Nurse 1 (LVN 1) went inside Resident 3 ' s room to Resident 3 ' s call light. LVN 1 looked at Resident 1 ' s call light button and said, His call light is broken, we are getting him another one.
During an observation on 4/18/2023 at 2:51 pm, MS and CNA 2 went inside Resident 1's room. MS replaced Resident 1 ' s call light, then CNA 2 handed Resident 1 the new call light button and asked Resident 1 to turn on his call light. Resident 1 pressed the call light button, and his call light came on.
During an interview on 4/20/2023 at 3:05 pm, LVN 3 stated call lights needed to always be within the resident ' s reach.
During an interview on 4/20/2023 at 3:54 pm, the DSD stated the call lights had to be within the resident ' s reach.
During an interview 4/26/2023 at 2:20 pm, the DON stated the call lights were supposed to placed where residents can reach it.
A review of the facility ' s policy and procedure titled, Answering the Call Light, dated 10/2010, indicated, The purpose of this procedure is to respond to the resident ' s requests and needs. The policy and procedure indicated, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. The policy and procedure further indicated, Report all defective call lights to the nurse supervisor promptly.
A review of the facility ' s policy and procedure titled, Supporting Activities of Daily Living, dated 3/2018, indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 2) skin and pressure ulcer/injury (wound caused by prolonged pressure on the...
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Based on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 2) skin and pressure ulcer/injury (wound caused by prolonged pressure on the skin) care and services according to the physician ' s orders and the resident ' s care plan by failing to ensure:
1. Resident 2's low air loss (LAL, provides airflow to keep skin dry) alternating pressure (redistributes pressure) mattress was set according to the physician ' s order.
2. Resident 2 was repositioned every two hours according to the resident ' s care plan.
3. Resident 2 did not have an adult brief (disposable underwear) underneath her while on a LAL alternating pressure mattress.
These deficient practices placed Resident 2 at risk for worsening pressure ulcers/injuries and to develop new pressure ulcers.
Cross Reference F726
Findings:
A review of Resident 2 ' s Face Sheet (admission record) indicated the facility admitted Resident 2 on 2/23/2022 with diagnoses that included chronic osteomyelitis (long-term infection of the bone), paraplegia (paralysis or severe or complete loss of feeling and movement in the lower half of the body), and stage 4 pressure ulcer/injury (wound that had gone through all the layers of the skin exposing muscle or bone and caused by prolonged pressure on the skin) of the sacral region (area between the lower back and the tailbone) and of the left buttock.
A review of Resident 2 ' s Physician Orders, dated 5/31/2022, indicated for Resident 2 to be on a pressure relieving LAL mattress set to alternating pressure and to the resident ' s weight for wound management.
A review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/1/2023, indicated Resident 2 had severely impaired cognitive (ability to think and reason) skills for decision making, had an indwelling urinary catheter (a flexible tube left inside the bladder and used to empty the bladder and collect urine in a drainage bag), had a colostomy (surgically created hole in the abdomen to allow feces to leave the body and collected in a bag), and was totally dependent on staff to move around in bed, to move to or from bed, chair, wheelchair, or standing position, to move to and from different locations in the facility, to dress, to use the toilet, and to maintain personal hygiene.
A review of Resident 2 ' s Risk for Skin Breakdown care plan dated 3/9/2023, indicated Resident 2 was at risk for skin breakdown due to the presence of pressure ulcers upon admission and obesity. The care plan goal was for Resident 2 to not to have any complications. The care plan interventions included to reposition Resident 2 at least every two hours, to provide perineal care (cleaning the genital area) every shift and as needed and to provide skin treatments according to the physician ' s orders. The care plan indicated to keep the resident clean and dry, to provide a pressure reduction mattress, and to keep the bed dry and wrinkle free.
A review of Resident 2 ' s untitled weight record, dated 4/5/2023, indicated Resident 2 weighed 150 pounds (lbs., a unit of weight).
During a wound treatment observation and interview with Licensed Vocational Nurse 2 (LVN 2) and Certified Nursing Assistant 4 (CNA 4) on 4/19/2023 at 2:07 pm, Resident 2's bed was set at 150 and there was an adult brief under Resident 2. After providing wound care, CNA 4 and LVN 2 placed a clean adult brief underneath Resident 2, positioned the resident with pillows, and then covered Resident 2 with a blanket. When LVN 2 was asked if Resident 2 needed to have an adult brief as a bed pad while on a LAL alternating pressure mattress, LVN 2 said, No. CNA 4 and LVN 2 turned Resident 2 again, removed the adult brief, placed a [brand name] incontinence (lack of voluntary control over urination or bowel movement) pad under the resident, positioned the resident with pillows, then covered the resident with a blanket. LVN 2 stated the correct setting for Resident 2's low air loss alternating pressure mattress was 150.
During an interview on 4/20/2023 at 1:22 pm, the Nurse Practitioner (NP) stated Resident 2 had a urinary catheter and a colostomy bag for wound management and needed to use a [brand name] incontinence pad and not an adult brief while on the LALalternating pressure mattress.
During an observation on 4/20/2023 at 2:10 pm, Resident 2 was sleeping in bed and was turned towards the door. Resident 2 ' s mattress was set at 450.
During an observation and interview on 4/20/2023 at 2:21 pm, the Unit Manager (UM) looked at Resident 2 ' s bed setting and saw the mattress was set at 450. The UM said, That is not the right bed setting. I just checked her weight, and she weighs 150, so the bed should be set at 150.
During an interview on 4/20/2023 at 3:05 pm, LVN 3 stated Resident 2 had pressure ulcers and had to be turned at least every two hours.
During an interview on 4/20/2023 at 3:54 pm, the Director of Staff Development (DSD) stated staff (in general) could only use breathable bed pads (designed for airflow therapy beds) or just a flat sheet on a LAL mattress.
During an observation on 4/20/2023 at 4:20 pm, Resident 2 was sleeping in bed and was turned towards the door.
During an interview on 4/20/2023 at 4:36 pm, CNA 6 stated she came in to work at 3 pm but had not been in Resident 2 ' s room yet. CNA 6 stated Resident 2 had a pressure ulcer and had to be repositioned every two hours. CNA 6 stated she did not know Resident 2 had not been repositioned since 1:30 pm.
During an interview on 4/21/2023 at 1:43 pm, the DSD stated the setting on the LAL mattress could only be changed by licensed nurses (in general). The DSD said, Residents can only have a flat sheet or only one layer of padding on a low air loss mattress because it defeats the purpose of pressure reduction.
A review of the facility policy and procedure titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, with a revised date of4/2018, indicated, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. The policy and procedure indicated, The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions.
A review of the facility policy and procedure titled, Support Surface Guidelines, with a revised date of 9/2013, indicated, Redistributing support surfaces are to promote comfort for all bed and chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Support surfaces alone are not effective in preventing pressure ulcers, but studies indicate that the use of appropriate support surfaces with interventions such as turning, repositioning, and moisture management can assist in reducing pressure ulcer development. The policy and procedure indicated, Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, static air, alternating air, gel, or air-loss device when lying in bed. For residents that recline and depend on staff for repositioning, change positions at least every 2 hours. Reposition residents who are in a chair at least every 2 hours.
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 1 an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 3) had access to fluids at the bedside.
This deficient practice placed Residents 1 and 3 at risk to not receive adequate fluid intake.
Findings:
A review of Resident 1 ' s Face Sheet (admission record) indicated the facility admitted Resident 1 on 10/21/2022 with diagnosis thatincluded rheumatoid arthritis (disorder that causes pain and inflammation of the joints).
A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/5/2023, indicated Resident 1 ' s cognitive (ability to think and reason) skills for decision making was intact. The MDS indicated Resident 1 was totally dependent on staff to move around in bed, to move to or from bed, chair, wheelchair, or standing position, to dress, to eat, to use the toilet, and to maintain personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, washing/drying face, and hands).
A review of Resident 3 ' s Face Sheet indicated the facility admitted Resident 3 on 2/15/2011 and readmitted the resident on 5/6/2021 with diagnosis of hemiplegia (paralysis or severe or complete loss of feeling and movement in the arm, leg, and sometimes face on one side of the body) following cerebral infarction (stroke, damage to tissues in the brain which occurs because of disrupted blood flow to the brain) affecting left nondominant side (paralysis of the left arm and left leg of a right-handed individual).
A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 had moderately impaired cognitive skills for decision making, had impaired movement of his left arm and left leg, had a colostomy (surgically created hole in the abdomen to allow feces to leave the body and into a bag), and was totally dependent on staff to move to or from bed, chair, wheelchair, or standing position, to move to and from different locations in the facility, to dress, to use the toilet, and to maintain personal hygiene. The MDS indicated Resident 3 required extensive assistance from staff to move around in bed and required limited assistance from staff to eat.
During an observation on 4/18/2023 at 2:22 pm, Residents 1 and 3 were in bed and their water pitchers were on top of their nightstand. Resident 1 ' s and Resident 3 ' s water pitchers were not within their reach.
During an interview with Resident 1 on 4/18/2023 at 3:03 pm, he said, Even if water pitcher is in reach I can ' t drink on my own. Resident 1 stated he needs water in a glass with a straw. Resident 1 further stated he would like the water pitcher closer to him.
During a concurrent observation and interview with Certified Nursing Assistant 3 (CNA 3) and Resident 1 on 4/19/2023 at 1:15 pm, Resident 1 was in bed and CNA 3 was observed at Resident 1 ' s bedside assisting the resident with lunch. There was a 4 ounces (oz, unit of measure) glass of red-colored juice, 4 oz carton of chocolate drink, and a 4 oz glass of milk on Resident 1 ' s tray. The paper dietary card (indicates diet type, food preferences, food consistency, size of food serving, liquid thickness, type of drink/liquid, and how much liquid to put on a meal tray) on Resident 1 ' s tray indicated to put 4 oz juice, 4 oz 2% (reduced fat) milk, and a chocolate shake on Resident 1 ' s meal tray. There was a water pitcher and an empty plastic cup with a straw on Resident 1 ' s nightstand which was out of Resident 1 ' s reach. CNA 3 stated he offered Resident 1 a drink of water every hour. Resident 1 stated he thinks he could use more water.
During an observation on 4/19/2023 at 1:25 pm, Resident 3 was sitting up in bed eating lunch on his own. Resident 3 ' s water pitcher was on his nightstand and was not within Resident 3 ' s reach.
During a concurrent observation and interview with Resident 1 on 4/20/2023 at 12:54 pm, Resident 1 was in bed and his water pitcher was on his nightstand and not within his reach. Resident 1 said, I only drank whatever was with my breakfast, a 4 ounces milk and same size chocolate drink and red juice. I also got some water with my medicine. Resident 1 stated he did not have any extra water to drink. Resident 1 said, I don ' t feel I ' ve had enough to drink today. At home I have a water decanter or bottled water by me all the time.
During a concurrent observation and interview with Resident 3 on 4/20/2023 at 1:07 pm, Resident 3 was sitting up in bed and his water pitcher was on his nightstand. Resident 3 said, I can ' t reach that (water pitcher). Resident 3 said, I don ' t think I get enough to drink. I only get what comes with my food.
During an interview with the Unit Manager (UM) on 4/20/2023 at 1:15 pm, the UM stated water pitchers needed to be placed by the residents so the residents could reach them.
During an interview with the Director of Staff Development (DSD) on 4/20/2023 at 3:54 pm, she stated even if a resident (in general)needed assistance with drinking water, the water pitcher still needed to be within the resident ' s reach.
During an interview with CNA 3 on 4/21/2023 at 12:51 pm, he said, Water pitcher has to be always on bedside table, but some (water pitcher) we put on the nightstand because they (residents) can ' t pour water on their own and they spill. CNA 3 stated residents whose water pitcher was placed on the nightstand, were told to call for assistance whenever they needed water. CNA 3 stated if a resident could not ask for assistance, he would offer them water every hour.
During an interview with CNA 9 on 4/21/2023 at 1:14 pm, she stated water pitchers needed to be within reach of the residents except for residents on fluid restriction (limiting fluids) or residents with a gastrostomy tube (G-tube, a tube surgically placed through the abdomen and into the stomach, and used to administer nutrition, liquids, or medications).
During an interview with the Director of Nursing (DON) on 4/26/2023 at 2:20 pm, she stated water pitchers are supposed to be placed where residents can reach them.
A review of the facility policy and procedure titled, Serving Drinking Water, dated 10/2010, indicated to place the water pitcher and cup within easy reach 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
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 2 (LVN 2), LVN 3, Ce...
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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 Licensed Vocational Nurse 2 (LVN 2), LVN 3, Certified Nursing Assistant 4 (CNA 4), CNA 5, and CNA 6, had the competency skills (the capability to apply or use the knowledge, and abilities required to successfully perform tasks in the work setting) to provide care to one of three sampled residents (Resident 2) who was on a low air loss (LAL, provides airflow to keep skin dry) alternating pressure (redistributes pressure) mattress for pressure ulcer/injury (wound caused by prolonged pressure on the skin) management.
This deficient practice had the potential for Resident 2 not to receive the appropriate care and services to manage her pressure ulcers/injuries.
Cross Reference F686
Findings:
A review of Resident 2 ' s Face Sheet (admission record) indicated the facility admitted Resident 2 on 2/23/2022 with diagnoses that included chronic osteomyelitis (long-term infection of the bone), paraplegia (paralysis or severe or complete loss of feeling and movement in the lower half of the body), and stage 4 pressure ulcer/Injury(wound that had gone through all the layers of the skin exposing muscle or bone and caused by prolonged pressure on the skin) of the sacral region (area between the lower back and the tailbone) and of the left buttock.
A review of Resident 2 ' s Physician Orders, dated 5/31/2022, indicated for Resident 2 to be on a pressure relieving LAL mattress set to alternating pressure and to theresident ' s weight for wound management.
A review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/1/2023, indicated Resident 2 had severely impaired cognitive (ability to think and reason) skills for decision making, had an indwelling urinary catheter (a flexible tube left inside the bladder and used to empty the bladder and collect urine in a drainage bag), had a colostomy (surgically created hole in the abdomen to allow feces to leave the body and collected in a bag), and was totally dependent on staff to move around in bed, to move to or from bed, chair, wheelchair, or standing position, to move to and from different locations in the facility, to dress, to use the toilet, and to maintain personal hygiene.
A review of Resident 2 ' s Risk for Skin Breakdown care plan dated 3/9/2023, indicated Resident 2 was at risk for skin breakdown due to the presence of pressure ulcers upon admission and obesity. The care plan goal was for Resident 2 to not to have any complications. The care plan interventions included to reposition Resident 2 at least every two hours, to provide perineal care (cleaning the genitalarea) every shift and as needed and to provide skin treatments according to the physician ' s orders. The care plan indicated to keep the resident clean and dry, to provide a pressure reduction mattress, and to keep the bed dry and wrinkle free.
A review of Resident 2 ' s untitledweight record, dated 4/5/2023, indicated Resident 2 weighed 150 pounds (lbs., a unit of weight).
A review the Nursing Assistant Orientation and Competency Evaluation Nursing Skills Performance Satisfactory Completion, dated 11/1/20, 4/9/21, and 9/22/22, indicated CNA 4 ' s, CNA 5 ' s, and CNA 6 ' s competency with LAL mattress and alternating pressure mattress were not evaluated.
A review the Licensed Nurse Clinical Skills Checklist, dated 2/3/20, and 6/8/22, indicated LVN 2, and LVN 3 competency with low air loss mattress and alternating pressure mattress were not evaluated.
During a wound treatmentobservation and interview with Licensed Vocational Nurse 2 (LVN 2) and Certified Nursing Assistant 4 (CNA 4) on 4/19/2023 at 2:07 pm, Resident 2 ' s bed was set at 150 and there was an adult brief under Resident 2. After providing wound care, CNA 4 and LVN 2 placed a clean adult brief underneath Resident 2, positioned the resident with pillows, and then covered Resident 2 with a blanket. When LVN 2 was asked if Resident 2 needed to have an adult brief as a bed pad while on a LAL alternating pressure mattress, LVN 2 said, No. CNA 4 and LVN 2 turned Resident 2 again, removed the adult brief, placed a [brand name] incontinence (lack of voluntary control over urination or bowel movement) pad under the resident, positioned the resident with pillows, then covered the resident with a blanket. LVN 2 stated the correct setting for Resident 2 ' s low air loss alternating pressure mattress was 150.
During an interview on 4/20/2023 at 1:22 pm, the Nurse Practitioner (NP) stated Resident 2 [NAME] urinary catheter and a colostomy bag for wound management and needed touse a [brand name] incontinence pad and not an adult brief while on theLAL alternating pressure mattress.
During an observation on 4/20/2023 at 2:10 pm, Resident 2 was sleeping in bed and was turned towards the door. Resident 2 ' s mattress was set at 450.
During an observation and interview on 4/20/2023 at 2:21 pm, the Unit Manager (UM) looked at Resident 2 ' s bed setting and saw the mattress was set at 450. The UM said, That is not the right bed setting. I just checked her weight, and she weighs 150, so the bed should be set at 150.
During an interview on 4/20/2023 at 2:25 pm, CNA 5 stated she was unsure of what Resident 2 ' s bed setting should be. CNA 5 said, I didn ' t check the [bed] setting this morning. CNA 5 stated she usually asks the treatment nurse (wound nurse) for help with Resident 2 ' s mattress. CNA 5 said, I last turned her [Resident 2] an hour ago around 1:30 pm. CNA 5 stated she turned Resident 2 every two hours.
During an interview on 4/20/2023 at 3:54 pm, Director of Staff Development (DSD) stated staff (in general) could only use breathable bed pads (designed for airflow therapy beds) or just a flat sheet on a low air loss mattress.
During an observation on 4/20/2023 at 4:20 pm, Resident 2 was sleeping in bed and was still turned towards the door.
During an interview on 4/20/2023 at 4:36 pm, CNA 6 stated she came in to work at 3 pm but had not been in Resident 2 ' s room yet. CNA 6 stated Resident 2 had a pressure ulcer and had to be repositioned every two hours. CNA 6 stated she did not know Resident 2 had not been repositioned since 1:30 pm.
During an interview on 4/21/2023 at 1:43 pm, the DSD stated the setting on the LAL mattress couldonly be changed by licensed nurses (in general). The DSD said, Residents can only have a flat sheet or only one layer of padding on a low air loss mattress because it defeats the purpose of pressure reduction.
During an interview with the Administrator and the Director of Nursing (DON) on 4/26/2023 at 1:15 pm, the Administrator said, The competencies [record] for staff did not include training on low air loss mattress. The DON stated the facility had previous in-service (training) on low air loss bed.
During an interview with LVN 1 on 4/26/2023 at 1:33 pm, she stated she had taken care of residents on low air loss bed and does not remember formal training on low air loss bed prior to caring for a resident on a low air loss bed.
During an interview with the DON on 4/26/2023 at 2:20pm, the DON said, Competency is standard and part of 3-day orientation. The DON stated the nursing staff (in general) needed to learn skills and competencies necessary for the job.
A review of the facility policy and procedure titled, Pressure Ulcers/Skin Breakdown – Clinical Protocol, with a revised date of4/2018, indicated, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. The policy and procedure indicated, The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions.
A review of the facility policy and procedure titled, Support Surface Guidelines, with a revised date of9/2013, indicated, Redistributing support surfaces are to promote comfort for all bed and chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Support surfaces alone are not effective in preventing pressure ulcers, but studies indicate that the use of appropriate support surfaces with interventions such as turning, repositioning, and moisture management can assist in reducing pressure ulcer development. The policy and procedure indicated, Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, static air, alternating air, gel, or air-loss device when lying in bed. For residents that recline and depend on staff for repositioning, change positions at least every 2 hours. Reposition residents who are in a chair at least every 2 hours.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow infection control practices for two of three s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow infection control practices for two of three sampled residents (Residents 2 and 3) by failing to ensure:
1. Certified Nursing Assistant 4 (CNA 4) washed his hands with soap and water after providing care to Resident 2, who had a Clostridium difficile (C. diff, bacteria that causes an infection of the large intestines and causes diarrhea) infection.
2. Resident 3 received assistance with hand hygiene (cleaning hands) before eating and with fingernail cleaning and trimming.
These deficient practices had the potential to spread infections.
Findings:
1. A review of Resident 2 ' s Face Sheet (admission record) indicated the facility admitted Resident 2 on 2/23/2022 with diagnoses that included chronic osteomyelitis (long-term infection of the bone), paraplegia (paralysis or severe or complete loss of feeling and movement in the lower half of the body), and stage 4 pressure ulcer/injury (wound that had gone through all the layers of the skin exposing muscle or bone and caused by prolonged pressure on the skin) of the sacral region (area between the lower back and the tailbone) and of the left buttock.
A review of Resident 2 ' s Physician Orders, dated 5/30/2022, indicated to place Resident 2 on Contact Isolation Precautions (precautions used for individuals known or suspected to be infected with microorganisms that can be transmitted by direct contact with the individual or indirect contact with environmental surfaces or items in the individual ' s environment) for multiple infections including C. diff infection.
A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had severely impaired cognitive (ability to think and reason) skills for decision making, had an indwelling urinary catheter (a flexible tube left inside the bladder and used to empty the bladder and collect urine in a drainage bag), had a colostomy bag, and was totally dependent on staff to move around in bed, to move to or from bed, chair, wheelchair, or standing position, to move to and from different locations in the facility, to dress, to use the toilet, and to maintain personal hygiene. The MDS indicated Resident 2 required staff supervision to eat.
A review of Resident 2 ' s physician orders, dated 4/6/2023, indicated for Resident 2 to take vancomycin (antibiotic, drug used to treat infections) 125 milligrams (mg, a unit of measure) by mouth four times a day until 4/22/2023 for C. diff infection.
During an observation on 4/20/2023 at 4:50 pm, CNA 4, CNA 6, and CNA 7 went inside Resident 2 ' s room and repositioned Resident 2 in bed.
During a subsequent observation on 4/20/2023 at 4:55 pm, CNA 4 removed his gown and gloves after repositioning Resident 2, walked out of Resident 2 ' s room, and performed hand hygiene by using the alcohol-based hand rub (ABHR) on the wall outside Resident 2 ' s room. CNA 4 did not go in the bathroom or the nurses ' station to wash his hands with soap and water. CNA 4 walked down the hall, opened the door to the linen closet, grabbed a clean resident gown out of the linen closet, walked back to the doorway of Resident 2 ' s room, and handed CNA 7, who was still inside Resident 2 ' s room, the resident gown.
During an interview with CNA 4 on 4/20/2023 at 4:58 pm, when asked if he needed to wash his hands with soap and water after caring for a resident with C. diff infection, CNA 4 stated he would wash his hands after he finished assisting CNA 6 and CNA 7 with Resident 2.
During an interview with the Infection Prevention Nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) on 4/20/2023 at 5:07 pm, he stated ABHR was effective against C. diff infections, but he would look up the information to be sure.
During a subsequent interview with the IPN on 4/20/2023 at 5:25 pm, he said, I looked it up and hand sanitizer is not effective against C. diff. Should only use bleach for cleaning and hand washing with soap and water.
A review of the facility ' s policy and procedure titled, Handwashing/Hand Hygiene, dated 8/2019, indicated the facility considers hand hygiene the primary means to prevent the spread of infections. The policy indicated, Wash hands with soap (antimicrobial or non-antimicrobial) and water when hands are visibly soiled and after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus (a very contagious virus that causes vomiting and diarrhea), salmonella (bacteria that causes stomach cramps, nausea and vomiting, fever, and headache), shigella (bacteria that causes severe diarrhea [often bloody], abdominal pain, stomach cramps, and fever), and C. difficile.
2. A review of Resident 3 ' s Face Sheet (admission record) indicated the facility admitted Resident 3 on 2/15/2011 and readmitted the resident on 5/6/2021 with diagnosis of hemiplegia (paralysis or severe or complete loss of feeling and movement in the arm, leg, and sometimes face on one side of the body) following cerebral infarction (stroke, damage to tissues in the brain which occurs because of disrupted blood flow to the brain) affecting left nondominant side (paralysis of the left arm and left leg of a right-handed individual).
A review of Resident 3 ' s ADL care plan, dated 9/2/2022, indicated Resident 3 required assistance with ADL due to left hemiplegia. The care plan goals were to increase ADL independence, to maintain ADL function, to be groomed daily, and to meet Resident 3 ' s ADL needs daily. The care plan interventions included to encourage independence, assist Resident 3with ADL as needed, monitor the resident for ADL needs, have the call light within the resident ' s reach, and for the staff to answer the call light promptly.
A review of Resident 3 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/14/2023, indicated Resident 3 had moderately impaired cognitive skills for decision making, had impaired movement of his left arm and left leg, had a colostomy (surgically created hole in the abdomen to allow feces to leave the body and into a bag), and was totally dependent on staff to move to or from bed, chair, wheelchair, or standing position, to move to and from different locations in the facility, to dress, to use the toilet, and to maintain personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, washing/drying face, and hands). The MDS indicated Resident 3 required extensive assistance from staff to move around in bed and required limited assistance from staff to eat.
During a concurrent observation and interview with Resident 3 on 4/20/2023 at 1:07 pm, Resident 3 was observed sitting up in bed eating lunch using his right hand. Resident 3 ' s right hand had brown, foul-smelling matter on it and his right-hand fingernails were long with dark brown, foul-smelling matter underneath the fingernails. When the surveyor asked Resident 3 about the brown matter on his right hand and under his fingernails, Resident 3 pointed to his colostomy bag and stated, That ' s from this.
During a concurrent observation and interview on 4/20/2023 at 1:15 pm, the Unit Manager (UM) stated Certified Nursing Assistants (CNAs) needed to provide nail care with ADL care daily and as needed. The UM looked at Resident 3 ' s right hand and fingernails and said, They (CNAs) need to clean his hands and cut his nails.
During an interview on 4/20/2023 at 3:54 pm, the Director of Staff Development (DSD) stated the residents ' (in general) hands, nails, and oral care were part of daily ADL care and provided as needed. The DSD stated when serving meals to the resident, staff (CNAs) needed to clean the resident ' s hands and offer hand sanitizer towelettes.
During an interview on 4/26/2023 at 2:20 pm, the Director of Nursing (DON) stated nail care and hand hygiene were part of the residents ' (in general) ADL care every shift.
A review of the facility ' s policy and procedure titled, Assisting the Resident with In-Room Meals, dated 12/2013, indicated, Be sure the resident is prepared to receive the meal (i.e., offered bedpan or urinal, face and hands washed, hair combed, etc.) before placing the tray on the resident ' s overbed table.
A review of the facility ' s policy and procedure titled, Handwashing/Hand Hygiene, dated 8/2019, indicated the facility considers hand hygiene (cleaning hands by either washing them with soap and water, or by using a hand sanitizer) the primary means to prevent the spread of infections. The policy indicated to perform hand hygiene before and after eating or handling food and after using the toilet or conducting personal hygiene.
A review of the facility ' s policy and procedure titled, Care of Fingernails/Toenails, dated 2/2018, indicated, The purposes of the procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The policy indicated, Nail care includes daily cleaning and regular trimming.
Reference
According to the Centers for Disease Control and Prevention (CDC), C. diff germs are carried from person to person in poop and washing hands with soap and water is the best way to prevent the spread from person to person. Prevent the Spread of C. diff | CDC
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled resident's electronic Medication Admini...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled resident's electronic Medication Administration Record (eMAR) was accurately documented. The eMAR for Resident 1's Fasting Blood Sugar check with 100 units/milliliter regular insulin (medication used to control blood sugar levels) coverage per sliding scale (a progressive increase in the insulin dose based on pre-defined blood sugar ranges) order was documented with a checkmark indicating it was done. The blood sugar result was also documented and it was below the sliding scale parameter for insulin coverage, however, an injection site was also documented, which could indicate that insulin was given. This could result to confusion on whether insulin was given even if the parameters per sliding scale was not met and could potentially put resident's health and well-being at risk.
Findings:
A review of Resident 1's Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (when the lungs can't get enough oxygen into the blood), with hypoxia (low oxygen in the body's tissues) or hypercapnia (a buildup of carbon dioxide in the bloodstream), attention to tracheostomy (a surgically created hole in the trachea or windpipe that provides an alternative airway for breathing), 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 for medication and/or nutrition), and type 2 diabetes mellitus (high blood sugar which results when the body doesn't use insulin properly). The Face Sheet also indicated Resident 1 was discharged on 3/4/2023.
A review of Resident 1's summary of physicians' orders for March 2023, indicated Resident 1 had an order, dated 3/1/2023, for a fasting blood sugar check with insulin regular 100 units/ml vial; to inject subcutaneously (SQ, injection given in the fatty tissue just under the skin), every 6 hours per sliding scale coverage for diabetes mellitus. The sliding scale coverage were as follows:
For blood sugar (BS) less than 200 = 0 no insulin ordered; for BS 201-250 = 2 units (insulin); for BS 251-300 = 3 units; for BS 301-350 = 4 units; for BS 351-399 = 5 units; and for BS below 70 or more than 400, call physician.
A review of Resident 1's eMAR indicated that the fasting blood sugar check with insulin regular 100 units/ml subcutaneously every 6 hours per sliding scale coverage was charted with a checkmark on 3/2/2023 at 12 AM, 6 AM, and 12 PM. The 12 AM dose indicated that the SQ injection site was on the left lower quadrant (LLQ) and the BS was 124; the 6 AM dose indicated the SQ injection site was on the right lower quadrant (RLQ) and the BS was 177; the 12 PM dose indicated the SQ injection site was on the left upper quadrant (LUQ) and the BS was 89.
A review of Resident 1's care plan for the risk of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes mellitus, dated 3/3/2023, indicated to administer medication/insulin as ordered per sliding scale.
During an interview on 4/20/2023 at 2:59 PM, Licensed Vocational Nurse 1 (LVN 1) stated, the checkmark on the eMAR means the medication (regular insulin) was given but she stated, that there were no amount/units charted meaning nothing was given. The nurse should have charted the eMAR with an N, meaning medication was not given, instead of a checkmark, because the BS was below the sliding scale parameter.
During an interview on 4/21/2023 at 10:00 AM, the Medical Records Director (MRD) stated, there was an error in entering the doctor's order in the eMAR for Resident 1. The order for the blood glucose check and the Insulin coverage per sliding scale should have been separated to allow the nurse to chart them separately. The checkmark on the eMAR means that the blood glucose order was done and the checkmark would allow the nurse to enter result. The MRD stated entering injection site on the eMAR does not mean that insulin was given but because the q6 hours blood glucose check and the insulin coverage order were entered together, the nurse would not be able to complete/close charting if no injection site was entered even if there was no insulin given. The MRD stated there was no units of insulin entered in the eMAR meaning there was no insulin given and the system would not allow the nurse to enter any amount because the blood glucose level was below the parameter. The injection site was entered only to close the charting but does not mean that insulin was given.
During an interview on 4/21/2023 at 10:41 AM, LVN 2 stated, she worked the night shift at the sub-acute and verified she was one of the LVN who charted in the eMAR for the blood glucose check with regular insulin coverage per sliding scale on 3/2/2023 for Resident 1. LVN 2 stated, she followed the sliding scale order for the insulin and would not give insulin if blood sugar level was below the parameter. LVN 2 stated, she charted the fasting blood sugar check with insulin sliding scale coverage order with a checkmark because she did the blood glucose check and would not be able to enter the result if she did not chart it with a checkmark. LVN 2 stated, the system would not let her close the charting entry if she did not enter any info the computer was asking and that was why she entered injection site to complete the charting even if no insulin was given. LVN 2 stated, she did not remember if she notified her supervisor about this error but would notify the supervisor if she encountered any system errors like this in the future so staff could properly document and avoid confusion.
During an interview on 4/21/2023 at 10:52 AM, LVN 3 stated, she only worked part-time, about twice a month. LVN 3 verified that she worked for this facility on 3/2/2023 and did the 12 PM blood sugar check order for Resident 1. LVN 3 stated, she did not give any insulin to Resident 1 because it was below the sliding scale parameters. LVN 3 stated, the checkmark she charted indicated that the blood sugar check was done and the result entered indicated that no insulin was needed. An injection site was entered only because the computer charting would not be complete if the information the computer was asking for was left blank. LVN 3 stated, this was an error in the computer program. LVN 3 stated, she did not remember if she notified anybody about this error but would do so if she encountered something like this again.
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
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 environment for one (Resident 1) of one sampled resident, re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure environment for one (Resident 1) of one sampled resident, reviewed for elopement, and was free of accident hazards. Resident one was able to elope from the facility possibly through an iron gate in the patio behind his room that leads to a small alley outside the facility.
This deficient practice resulted in Resident 1 eloped from the facility and had the potential risk for Resident 1 to sustain injury from being on his own and unsupervised outside of the facility.
Findings:
A review of the admission record (face sheet) for Resident 1 indicated the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), urinary tract infection (an infection in any part of the urinary system, which includes the kidneys, bladder, ureters, and urethra), unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and anxiety disorder (persistent and excessive worry that interferes with daily activities).
A review of the facility's Reported Incident, dated 2/17/23, indicated on 2/16/23, Resident 1 was in Resident 1's room at 3:15 pm. After 5 minutes, when a Certified Nursing Assistant (CNA, unidentified) returned to Resident 1's room, she could not find Resident 1 in Resident 1's room or in the facility. The report indicated facility's staff found resident 1 at a local hospital at 4:40 pm (the local hospital is 0.2 mile from the facility).
A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) for Resident 1, dated 2/22/2023, indicated Resident 1 has clear speech, adequate hearing, and usually has the ability to make self-understood and understand others. The MDS indicated Resident 1 has a short- and long-term memory problem, and his cognitive skills for daily decision making is moderately impaired. The MDS indicated Resident 1 required supervision from staff for bed mobility, transfer to and from bed, walk in room and corridor, locomotion on and off the unit, eating, and toilet use. The MDS indicated Resident 1 required limited assistance from staff for personal hygiene and dressing. The MDS further indicated that Resident 1 does not have any functional limitations in range of motion for his upper and lower extremities and does not use any mobility device.
A review of the summary of the physicians' orders for Resident 1 indicated the resident had an order for Seroquel (Quetiapine, an antipsychotic medicine that works by changing the actions of chemicals in the brain) 50 milligrams (mg) tablet; give three tablets (150 mg) by mouth twice daily for psychosis manifested by hallucinations (sensing things such as visions, sounds, or smells that seem real but are not) of seeing family members who are not there. Resident 1 also had an order for Citalopram HBR (citalopram hydrobromide, a medication that works by helping to restore the balance of a certain natural substance in the brain) 40 mg tablet; give 1 tablet by mouth daily for depression manifested by episodes of fearfulness.
A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR, a framework for communication between members of the health care team about a patient's condition) dated 2/16/2023, indicated that at around 3:30 PM, a Certified Nursing Assistant 1 (CNA 1) reported Resident 1 was not in his room, and a search for Resident 1 in the facility was done but could not locate the resident. The SBAR indicated the sliding door in Resident 1's room exiting towards the outside patio was noted open and a search in and outside the facility was conducted but they were to locate the resident. The SBAR also indicated that the Administrator (ADM) and Director of Nursing (DON) were aware and assigned staff to drive around facility to search for Resident 1. The SBAR further indicated the responsible party for Resident 1 and local law enforcement along with the resident's physician were notified about Resident 1 leaving the facility without permission.
During an observation on 3/2/2023 at 12:30, Resident 1's room at the time of the incident was noted to have a sliding glass door that leads to a patio outside the resident's room. The sliding door inside resident's room was unlocked and can be opened from inside the room.
During an observation and concurrent interview with the ADM on 3/2/2023 at 12:45 PM, the patio outside Resident 1's room with a gate that leads to an alley outside the facility. The ADM stated the iron gate was always padlocked and is opened only for deliveries of supplies to the facility and for staff to take out the trash to the alley outside the facility.
During an interview with a janitor (Staff 1) on 3/2/2023 at 12:50 PM, she stated that she uses the gate in the patio outside Resident 1's room to bring the trash bin outside the facility and opens the gate for deliveries. Staff 1 stated the key for the gate is kept in the laundry room for whoever needs it. Staff 1 stated she was on duty 1:30 PM to 8:30 PM on 2/16/2023. Staff 1 stated she used the gate around 3 PM to throw trash outside of the facility. Staff 1 stated she padlocked it again after throwing the thrash. Staff 1 stated she did not see Resident 1 left the facility through the gate at that time.
During an interview with the DON on 3/2/2023 at 1:30 PM, the DON stated that she was in the facility when Resident 1 eloped. The DON stated she drove around the facility with Licensed Vocational Nurse 1 (LVN 1) and CNA 1, to look for Resident. The DON stated that the resident was newly admitted to the facility the day before incident.
During an observation and concurrent interview with Resident 1 on 3/2/2023 at 1:45 PM, Resident was observed in his new room in Nurse Station 3 (Secured Memory Care Unit). Resident 1 was lying in bed, awake, looks comfortable with no signs of anxiety or pain. Resident 1 stated he is okay and has no pain. There were no notable signs of physical injury from the elopement. Bridge of nose has no sign of injury or bruise and left big toe has no sign of any abrasion. Resident 1 does not remember that he eloped or why he left the facility.
During an observation and concurrent interview with LVN 1 on 3/29/2023 at 1:55 PM, the iron gate in the patio outside Resident 1's room at the time of the elopement was observed to be unlocked. The gate was closed but the padlock was open. There was nobody in the patio except for one facility staff who was observed going inside the facility from the patio. LVN 1 confirmed that the gate was unlocked and stated that it should always be locked.
A review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated revised in July 2017, indicated that risk and safety hazards in the facility are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting process. The policy also indicated that resident supervision is a core component of the systems approach to safety.
Mar 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the sp...
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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 interventions to prevent and control the spread of Candida auris [C. auris, an emerging yeast (a type of fungus/microorganism that is found almost everywhere) infection (a condition in which too much yeast grows in certain areas of the body and causes symptoms and disease) causing severe illness in individuals and does not respond to commonly used antifungal (a drug used to treat fungal infections) medications] in accordance with the public health guidelines and the facility's policy and procedures for two of three sampled residents (Resident 1 and 2) on transmission-based precautions (TBP, additional infection control strategies applied to residents known or suspected to be infected or colonized with infectious agents to prevent transmission).
a. Certified Nursing Assistant 2 (CNA 2) did not don the required personal protective equipment (PPE, equipment worn to minimize exposure to workplace hazards) prior to entering Resident 1's room.
b. CNA 3 did not don the required PPE prior to entering Resident 2's room.
These deficient practices had the potential to cause the spread of C. auris infection in the facility.
Findings:
a. On 3/3/2023 at 1:49 p.m., an unannounced onsite visit was conducted at the facility due to a complaint related to infection control.
A review of Resident 1's Face Sheet indicated the facility initially admitted the resident on 2/21/2023, with multiple diagnoses including respiratory failure with tracheostomy (incision in the windpipe to insert a tube that can deliver oxygen to the lung related to inability to breathe normally), dysphagia (difficulty in swallowing) with gastrostomy (surgical operation to create an opening in the stomach to deliver food), and type 2 diabetes mellitus (chronic condition wherein body does not produce enough insulin or resists insulin, leading to high blood sugar) with diabetic chronic kidney disease.
A review of Resident 1's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 2/27/2023, indicated Resident 1 had severe impairment in cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 1 was totally dependent on staff with transfers, dressing, eating, toilet use, personal hygiene, and bathing.
A review of Resident 1's Physician Orders for 3/2023 indicated an order, dated 2/22/2023, to place Resident 1 in contact isolation (type of TBP used when infectious agents are potentially spread by direct or indirect contact with the resident or the resident's environment) for C. auris.
During an observation on 3/3/2023 at 2:37 p.m., CNA 2 entered the room of Resident 1, who was on contact isolation for C. auris, without first donning gown and gloves. CNA 2 donned gown and gloves while inside Resident 1's room. During a concurrent interview, CNA 2 stated the required PPEs must be donned prior to entering Resident 1's room for infection control.
During an interview on 3/3/2023 at 2:57 p.m., Social Services Staff 1 (SSS 1) stated all staff must wear the required PPE prior to entering the resident's room placed in contact isolation for C. auris, doff the PPE and place them in the trash can inside the room prior to exiting the resident's room, and then use a hand sanitizer.
During an interview on 3/3/2023 at 3:18 p.m., the Director of Nursing (DON) stated required PPE must be donned prior to entering the resident's room on TBP to prevent the possible transmission of C. auris.
b. A review of Resident 2's Face Sheet indicated the facility initially admitted the resident on 10/24/2022, with multiple diagnoses including respiratory failure and hypertensive heart disease (pathological changes in the heart due to high blood pressure).
A review of Resident 2's MDS, dated [DATE], indicated the resident did not have an impairment in cognition. The MDS indicated Resident 2 was totally dependent on staff with transfers, dressing, and toilet use.
A review of Resident 2's Physician Orders for 3/2023 indicated an order, dated 1/26/2023, to place Resident 2 on contact isolation for C. auris.
During an observation on 3/3/2023 at 4:12 p.m. with Licensed Vocational Nurse 1 (LVN 1), CNA 3 entered the room of Resident 2, who was on contact isolation for C. auris, without donning gown and gloves. During a concurrent interview, LVN 1 stated CNA 3 should have worn gown and gloves, in addition to the facemask and eye protection, for infection control and prevent cross-contamination.
During an interview on 3/3/2023 at 4:30 p.m., Infection Preventionist 1 (IP 1, responsible for the facility's infection prevention and control program which is designed to provide a safe, sanitary, and
comfortable environment and to help prevent the development and transmission of communicable diseases and infections) stated the staff must don the required PPE including gown and gloves prior to entering the resident room placed on contact isolation precautions to prevent the spread of the infection.
A review of the facility's policy and procedures titled, Infection Control Guidelines for All Nursing Procedures, dated 8/2012, indicated TBP must be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection.
A review of the local public health guidance titled, Candida auris, undated, indicated the following strategies to prevent the spread of C. auris:
1. Paying meticulous attention to infection prevention and control, including good hand hygiene; proper selection, use, and disposal of PPE; and appropriate and effective environmental cleaning and disinfection using an agent effective against C. auris.
2. Reviewing all interim recommendations from the Centers for Disease Control and Prevention (CDC), including monitoring the CDC website for new information and revisions to current recommendations.
[Source: http://publichealth.lacounty.gov/acd/Diseases/CandidaAuris.htm]
A review of the CDC guidance titled, Transmission-Based Precautions, dated 1/7/2016, included an example of a contact precautions signage to be posted outside the resident rooms that indicated the procedures: Put on gloves before room entry and Put on gown before room entry.
[Source: https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html]
A review of the CDC guidance titled, Infection Prevention and Control for Candida auris, dated 1/17/2023, indicated the following:
1. In nursing homes, including skilled nursing facilities, residents with C. auris must be managed using either contact precautions or enhanced barrier precautions (EBP, infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities), depending on the situation and local or state jurisdiction recommendations.
2. Adherence to appropriate infection control practices must be monitored by performing audits and providing feedback on hand hygiene practices, donning and doffing of gowns and gloves, and environmental cleaning and disinfection and by increasing the number of audits performed on units with C. auris cases.
[Source: https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html]
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID-...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (minor to severe respiratory illness caused by a virus and spread from person to person) in accordance with the facility's policies and procedures by failing to ensure all staff (Registered Nurse 2 (RN 2) and Certified Nurse Assistant 1 (CNA 1) were being tested weekly for COVID-19.
This deficient practice had the potential to further increase the spread of COVID-19 infection in the facility.
Findings:
During an interview on 1/25/2023 at 10:14 AM, Infection Preventionist 1(IP 1, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) stated, RN 2 was not tested for COVID-19 last week.
During an interview on 1/25/2023 at 10:42 AM, IP 1 stated, RN 2 had missed his weekly COVID-19 testing, several different times.
During an interview on 1/25/2023 at 10:55 AM, the Administrator (ADM) stated, all staff were required to be tested weekly for COVID-19. The ADM stated, that if staff are tested at the front entrance, they are to take a picture of the test result and the documentation they fill out in case the documentation was lost. The ADM stated, RN 2 did not test last week as required.
The ADM stated, RN 2 did not have a picture of last week's test result or documentation verifying he was tested as required.
During an interview on 1/25/2023 at 10:59 AM, IP 1 stated, RN 2 and CNA 1 did not comply with the COVID-19 testing requirements.
During an interview and concurrent record review on 1/25/2023 at 1:10 PM, CNA 1's and RN 2's COVID-19 Rapid Antigen Test documents and timecards were reviewed. IP 2 verified CNA 1 was tested on [DATE] and 1/22/2023 (more than 7 days apart). IP 2 verified a review of CNA 1's timecard indicated she worked on 1/10, 1/11, 1/12, 1/15, 1/16, 1/17, 1/18, 1/21, and 1/22/2023. IP 2 verified RN 2's last test document was dated 1/11/2023. IP 2 stated RN 2 had missed last week's testing requirement. IP 2 verified a review of RN 2's timecard indicated he worked on 1/11, 1/12, 1/13, 1/16, 1/17, 1/18, 1/12, 1/21, 1/22, and 1/23/2023.
During a telephone interview on 1/25/2023 at 4:58 PM, RN 2 stated, that he tested but did not send a picture of his test result to facility management. RN 2 stated, that he put the documentation in the bin after he tested.
A review of the facility's, COVID-19 Mitigation and Testing Plan, updated 12/9/2022, indicated that, during an outbreak, all staff must test regardless of vaccination status weekly unless otherwise directed by the PHN (Public Health Nurse).
Dec 2022
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (minor to severe respiratory illness caused by a new virus and sprea...
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Based on interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (minor to severe respiratory illness caused by a new virus and spread from person to person) by failing to ensure documentation of medical exemption from the COVID-19 vaccine/s indicated all information required in accordance with the Public Health guidelines and the facility ' s policies and procedures.
This deficient practice had the potential to further increase the spread of COVID-19 infection in the facility.
Findings:
On 12/7/2022 at 1:17 p.m., a follow-up complaint onsite visit regarding infection control was conducted at the facility.
A review of the facility ' s document, titled COVID-19 Vaccine Refusal – Staff, undated, indicated Certified Nursing Assistant 1 (CNA 1) was granted medical exemption.
A review of the CNA 1 ' s document from the healthcare provider, titled Certification of Qualified Medical Exemption, dated 9/17/2021, indicated CNA 1 was qualified for a Medical Exemption and should not be vaccinated for COVID-19 at this time. The document did not indicate the following:
a. Which COVID-19 vaccine/s were clinically contraindicated for the staff
b. The recognized clinical reasons for the contraindication
During a telephone interview on 12/12/2022 at 11:04 a.m., Infection Preventionist 2 (IP 2) stated for staff medical exemption requests, it was not required to indicate the reason why the staff could not receive the COVID-19 vaccine for staff privacy. IP 2 stated he was not aware of the required documentation per public health guidance on staff COVID-19 vaccination refusals.
A review of the facility ' s policies and procedures, titled Refusal of COVID-19 Vaccination, Staff, undated, indicated the following:
a. All staff will be offered vaccines that aid in preventing infectious diseases such as COVID-19 Vaccine unless the vaccine is medically contraindicated and for religious belief.
b. Detailed information related to the refusal must be entered into the employee health record, including the employee condition and any adverse effects due to such refusal.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the sp...
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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 interventions to prevent and control the spread of COVID-19 (minor to severe respiratory illness caused by a new virus and spread from person to person) in accordance with Centers for Medicare and Medicaid Services (CMS, federal agency that administers the nation's major healthcare programs), Center of Disease Control and Prevention (CDC, a U.S. federal government agency whose mission is to protect public health by preventing and controlling disease, injury, disability) the local Public Health guidelines and the facility ' s policies and procedures by failing to:
a. Ensure all of the residents were cohorted per facility ' s COVID-19 mitigation plan upon the start of COVID-19 outbreak.
b. Ensure two of two staff (Certified Nurse Assistant 8 (CNA 8) and Certified Nurse Assistant 9 (CNA 9) donned and doffed proper personal protective equipment (PPE - gowns, gloves, face shields or goggles and N95 masks [respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) upon entering and exiting Resident 9 ' s room placed in transmission-based precautions and/or while providing resident care and within six-feet of a Covid-19 infected resident (Resident 10).
c. Ensure proper disposal of potentially contaminated PPEs per facility ' s policies and procedures.
d. Ensure all COVID signage were posted in the main entrance and in front of yellow zone rooms.
These deficient practices had the potential to spread COVID-19 from residents to other residents and staff in the facility and can lead to other respiratory illness, hospitalization and/or death.
Findings:
a. During an interview on an unannounced onsite infection control visit, on 11/10/2022 at 9:41 am, the Administrator stated the facility was on an active COVID-19 outbreak (indicates potentially extensive transmission within a setting or organization) since 10/31/2022. The ADM stated the facility had two cohorted zone; a red zone (RZ, area for residents who tested positive for COVID-19) and a green zone (GR, area where COVID-19 virus is under control).
A review of a face sheet (admission record) indicated Resident 11 was re-admitted to the facility on [DATE] with diagnosis that included diabetes (blood sugar, levels are too high) and obesity (condition of being grossly fat or overweight).
A review of a COVID-19 Final Report lab results, dated 11/7/2022, indicated Resident 11 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 12 was re-admitted to the facility on [DATE] with diagnosis that included hypertension (elevated blood pressure) and low back pain.
A review of a COVID-19 Final Report lab results, dated 11/7/2022, indicated Resident 12 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 13 was re-admitted to the facility on [DATE] with diagnosis that included psychosis (abnormal condition of the mind that involves a loss of contact with reality) and lack of coordination.
A review of a COVID-19 Final Report lab results, dated 11/7/2022, indicated Resident 13 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 14 was re-admitted to the facility on [DATE] with diagnosis that included peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and anxiety disorder (a feeling of worry, nervousness, or unease).
A review of a COVID-19 Final Report lab results, dated 11/7/2022, indicated Resident 14 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 15 was re-admitted to the facility on [DATE] with diagnosis that included depression (causes feelings of sadness and/or a loss of interest in activities once enjoyed) and obesity (condition of being grossly fat or overweight).
A review of a COVID-19 Final Report lab results, dated 11/7/2022, indicated Resident 15 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 17 was admitted to the facility on [DATE] with diagnosis that included diabetes (blood sugar, levels are too high) and lack of coordination.
A review of a COVID-19 Final Report lab results, dated 11/7/2022, indicated Resident 17 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 18 was admitted to the facility on [DATE] with diagnosis that included diabetes (blood sugar, levels are too high) and lack of coordination.
A review of a COVID-19 Final Report lab results, dated 11/7/2022, indicated Resident 18 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 19 was admitted to the facility on [DATE] with diagnosis that included atrial fibrillation (irregular heartbeats) and chronic pain.
A review of a COVID-19 Final Report lab results, dated 11/7/2022, indicated Resident 19 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 20 was re-admitted to the facility on [DATE] with diagnosis that included malignant neoplasm (cancer, A disease in which abnormal cells divide uncontrollably and destroy body tissue) and generalized muscle weakness.
A review of a COVID-19 Final Report lab results, dated 11/7/2022, indicated Resident 20 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 21 was re-admitted to the facility on [DATE] with diagnosis that included cervical spondylosis (age-related wear and tear of the spinal disks) and urinary track infection (UTI, an infection in any part of the urinary system, the kidneys, bladder, or urethra).
A review of a COVID-19 Final Report lab results, dated 11/7/2022, indicated Resident 21 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 22 was re-admitted to the facility on [DATE] with diagnosis that included hypertensive heart disease (elevated blood pressure) and depression (causes feelings of sadness and/or a loss of interest in activities once enjoyed).
A review of a COVID-19 Final Report lab results, dated 11/14/2022, indicated Resident 22 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 23 was admitted to the facility on [DATE] with diagnosis that included depression (causes feelings of sadness and/or a loss of interest in activities once enjoyed) and obesity (condition of being grossly fat or overweight)
A review of a COVID-19 Final Report lab results, dated 11/14/2022, indicated Resident 23 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 24 was re-admitted to the facility on [DATE] with diagnosis that included diabetes osteoarthritis (degeneration of joint cartilage and the underlying bone) and gastroesophageal reflux disease (GERD, stomach acid or bile irritates the food pipe lining).
A review of a COVID-19 Final Report lab results, dated 11/14/2022, indicated Resident 24 tested positive for COVID-19.
A review of a face sheet (admission record) indicated Resident 25 was admitted to the facility on [DATE] with diagnosis that included diabetes (blood sugar, levels are too high) and obesity (condition of being grossly fat or overweight).
A review of a face sheet (admission record) indicated Resident 26 was admitted to the facility on [DATE] with diagnosis that included psychosis (abnormal condition of the mind that involves a loss of contact with reality) and muscle spasms.
A review of a face sheet (admission record) indicated Resident 27 was admitted to the facility on [DATE] with diagnosis that included hyperlipidemia (high concentration of fats or lipids in the blood) and contact with and suspected exposure to COVID-19.
A review of a face sheet (admission record) indicated Resident 28 was admitted to the facility on [DATE] with diagnosis that included insomnia (inability to sleep) and contact with and suspected exposure to COVID-19.
A review of the facility ' s Line Listing for COVID-19 outbreak dated 10/28/2022 indicated Residents 10, 11, 12, 13, 14, 15, 17, 18, 19, 20 and 21 tested positive for COVID-19 on 11/7/2022
A record review of a document titled Positive Residents From 11/7/2022 - 11/21/2022, indicated Residents 22, 25, 26, 27, and 28 tested COVID-19 negative and were roommates with COVID-19 positive residents as follows:
COVID-19 positive Roommate with:
a. Resident 10 Resident 26
b. Resident 11 Resident 22
c. Residents 12 Resident 27
d. Residents 16 Resident 28
e. Residents 20 Resident 25
During an initial tour of the facility, with the facility assigned Public Health Nurse (PHN) on 11/10/2022 from 12:40 pm to 1:47 pm, no Yellow Zone (YZ, area for persons with suspected or undetermined illness) rooms was noted at the facility in all six stations. Residents 22, 25, 26, 27 and 28 where house in rooms in the GZ.
During an interview on 11/10/2022 at 1:53 pm, PHN stated a yellow zone is required especially during an active COVID-19 OB. PHN stated it was important to have a yellow zone due to exposed residents. The whole point was to rule out and make sure it (COVID) does not spread. PHN also stated she was not informed the facility did not have a YZ and if informed, she would have instructed and remined the facility that during an OB, it was crucial and importance of cohorting residents to prevent the spread of COVID-19.
During an interview and concurrent record review of the facility map, submitted on 11/10/2022, on 11/10/2022 at 2:25 pm, IP 2 confirmed the facility had two cohorted zones: RZ consisted of rooms 603, 604, 605, 606, 607, 608, 609, 610, 611, 612 and 614 (total of 11 rooms) and the remaining resident rooms at the facility was considered GZ room. IP 2 stated on 11/8/2022 the administration team decided to place all resident who tested negative in the GZ, whether they were exposed to COVID-19 or not following the AFL (All Facility Letter) 23-13.1 guidelines. IP 2 stated he should have informed the facility assigned PHN of the facility not having a YZ and is now aware of how important cohorting. IP 2 stated especially during a COVID-19 OB cohorting was important to better monitor exposed residents for COVID-19 symptoms and control the spread of infection.
During an interview on 11/10/2022 at 2:47 pm, the Director of Nursing stated the facility did not have a YZ from 11/8/2022 to 11/10/2022. DON stated residents who shared a room with a COVID-19 positive resident was considered an exposed resident and needed to be quarantined. Those residents needed to be closer monitored for any COVID-19 symptoms. DON stated those residents were exposed and if not isolated can spread COVID-19 to others.
During an interview and concurrent record review on 12/8/2022 at 1:26 pm, IP 2 stated Residents 10, 11, 12, 13, 14, 15, 17, 18, 19, 20 and 21 who tested COVID-19 positive on 11/7/2022 were moved to the RZ, however, their roommates who were exposed stayed in the YZ and was coverted into the GZ two days later on 11/8/2022. IP 2 stated exposed residents should remain in the YZ to be monitored for signs and symptoms of COVID-19. During an COVID-19 OB, the facility should have a yellow zone, exposed residents should be quarantined to contain the spread of COVID-19 and close the OB earlier. IP 2 stated extra precautions should have been in place.
A review of the facility ' s Mitigation Plan, updated on 8/25/2022, indicated it is the policy of this facility to protect our residents, staff and others who may be in our facility from harm during emergency events. To accomplish this, we have developed procedures for cohorting COVID-19 positive residents, suspected (PUI), untested, resident who is confirmed negative. After an outbreak or the discovery of COVID in our building we will divide up the residents into color coded groups for cohorting. Red for confirmed positive residents. Yellow for those suspected (PUI), untested, unvaccinated new admit, unvaccinated re-admit and unvaccinated dialysis.
A review of the facility ' s policy titled Infection Control - COVID-19 Management in Long Term Care (LTC), revised on 10/6/2022, indicated to provide a safe environment for residents andstaff ad to prevent the development and transmission of COVID-19. Cohorting fo Yellow Zone (YZ) Cohort - residents close contact/exposed in the same unit/wing regardless of individual resident vaccination status.
A review of the facility ' s policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised on 4/2020, indicated for residents with known or suspected COVID-19: residents placed in a private room with dedicated bathroom. Resident is cohorted per national, state, or local public health authority recommendations.
A review of the facility ' s COVID-19 Outbreak Notification Letter from the facility assigned PHN, dated 10/31/2022, indicated to adhere to LAC DPH ' s Guidance for Cohorting Residents including those who have tested positive for COVID-19, those who are displaying any symptoms associated with COVID-19, and those with exposure/close contact with a COVID-19 case.
A review of the Los Angeles County Department of Public Health guidance, titled Coronavirus 2019: Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, dated 9/27/2022, indicated the following:
1. Establish cohorting plan as part of California Department of Public Health (CDPH)-required COVID-19 mitigation plan.
2.COVID-19 vaccination up to date definition now includes receipt of the updated (bivalent) booster dose at least 2 months after completion of the primary series or last monovalent booster dose per CDC recommendations released 9/2/2022.
3.With regard to resident cohorting, the following are indications to quarantine residents in the Yellow Cohort (mixed quarantine and symptomatic cohort):
a. New admissions, readmissions, left the facility for more than 24 hours AND not up to date with all recommended COVID vaccine doses.
b.Symptomatic residents
c.Indeterminate COVID-19 test result
d.Close contacts, exposed to a confirmed COVID-19 case in the same unit/wing AND less than 90% of residents and staff are up to date with all recommended COVID vaccine doses.
3.Staff must follow transmission-based precautions for each cohort including standard precautions and wearing of appropriate personal protective equipment (PPE), such as N95 respirators, eye protection, gown, and gloves while providing care for residents in the Yellow Cohort.
[Source: http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/prevention/]
A review of the Centers for Disease Control and Prevention (CDC) guidance, titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 9/23/2022, indicated the following:
1. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction ' s public health authority.
2. Place residents with suspected or confirmed SARS-CoV-2 infection in a single-person room.
3. The door must be kept closed, if safe to do so.
4. Ideally, the resident should have a dedicated bathroom.
[Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html]
b. A review of Resident 9 ' s Face Sheet indicated the facility admitted Resident 9 on 11/11/2022 with diagnoses that included epilepsy (a sudden, uncontrolled electrical disturbance in the brain) and generalized muscle weakness.
A review of Resident 9 ' s care plan, titled Potential Exposure to Corona Virus (Covid-19), re-evaluated on 12/6/2022, indicated Resident 9 was exposed to COVID-19 and was placed immediately under enhanced contact/droplet precautions (isolation).
During an observation on 12/7/2022 at 2:25 pm, Certified Nurse Assistant 9 (CNA 9) was observed leaving Resident 9 ' s Yellow Zone (YZ - area designated for residents suspected with COVID-19 infection, in close contact with a COVID-19 case, or admitted to the facility and were unvaccinated) room while removing her used disposable gown. With her used gown in hand, CNA 9 proceeded to exit the YZ room, and disposed of the used gown in a trash bin located in the hallway. During a concurrent observation, a trash can was observed located in the middle of YZ room, away from the entrance/exit door.
During an interview on 12/7/2022 at 2:30 pm, CNA 9 stated she should have completely doffed (remove) and disposed of her soiled gown inside the YZ room to avoid the spread of contamination.
During an interview on 12/7/2022 at 2:32 pm, the Infection Control Preventionist 1 (IP 1, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) stated it was important to doff used gowns inside YZ/isolation room to prevent the spread of Covid-19. IP 1 stated lidded trash cans should have been placed next to the exit doors of a YZ room for accessibility and infection control purposes.
A review of Resident 10 ' s Face Sheet indicated the facility readmitted the resident to the facility on 7/11/2022 with diagnoses that included diabetes (elevated blood sugar), anxiety (intense, excessive, and persistent worry and fear about everyday situations).
A review of Resident 10 ' s COVID-19 Final Report lab results, dated 11/8/2022, indicated Resident 10 tested positive for COVID-19.
A review of Resident 10 ' s physician ' s order, dated 11/9/2022, indicated for Resident 10 to be on enhanced droplet and contact isolation (used to help keep individuals safe from diseases that spread through the air from person to person), due to COVID-19 for ten days.
During an observation in the facility ' s Red Zone (RZ, area for residents who tested positive for COVID-19) and concurrent interview, on 11/10/2022 at 1:39 pm, CNA 8 was observed in the hallway, rendering care to Resident 10. CNA 8 was not wearing gloves while touching Resident 10 ' s back and shoulder. CNA 8 stated he should have been wearing gloves while assisting Resident 10 because the resident was COVID-19 positive and could spread COVID-19.
During an interview on 11/10/2022 at 1:41 pm, Licensed Vocational Nurse 5 (LVN 5) stated proper PPE ' s should be worn at all times, especially during care in the RZ to stop the spread of COVID-19.
A review of the Centers for Disease Control and Prevention (CDC) guidance, titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 9/23/2022, indicated the following:
1. The facility must stay connected with the healthcare-associated infection program in their state health department, as well as their local health department, and their notification requirements.
2. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction ' s public health authority.
3. The facility must ensure everyone is aware of recommended IPC practices in the facility by posting visual alerts, such as signs and posters, at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) These alerts should include instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can let help ensure people know that they reflect current recommendations.
4. Healthcare providers who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).
5. Management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures.
A review of the Los Angeles County Department of Public Health guidance, titled Coronavirus 2019: Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, dated 9/27/2022, indicated the following:
1. Facilities must regularly audit their HCP ' s adherence to appropriate PPE use.
2. Post appropriate Transmission-Based Precautions signage outside of each resident room.
3. Post signage on the appropriate steps for donning and doffing PPE in donning and doffing areas.
4. As part of standard precautions for all resident care, gloves should be changed between every resident encounter.
5. Gowns should be used for each resident encounter in Yellow and Red cohorts for COVID-19 precautions including in resident rooms, shower rooms, rehab gyms, and other areas where close contact may occur during resident care.
6. Gowns should be donned prior to entering and doffed prior to exiting resident care areas, which includes but are not limited to resident rooms and shared shower rooms. Gowns worn during close contact activities must be doffed prior to re-entering common areas, e.g., hallways.
7. Re-use (over multiple days) and extended use (over multiple residents) of gowns are not allowed.
c. During an observation and concurrent interview, in the soiled linen sorting room and with Laundry Staff (LS) on 11/7/2022 at 2:57 pm, two visibly soiled disposable gowns were observed packaged and unlabeled (without staff ' s name) hanging directly above the clean Personal Protective Equipment (PPE, gown, gloves, mask and face shield) cart and the other was hanging on a hose rod. LS stated she just removed and hung up the down prior to leaving the dirty lined room. LS further stated the disposable gown was used shorting the facility ' s dirty linen and was soiled. LS stated she should have thrown the disposable gown away because the gown was dirty and may have infections that could potentially spread to the residents.
During an interview on 12/8/2022, at 1:26 pm, Infection Control Preventionist 2 (IP 2) stated used disposable gowns should not be reused. Staff members were instructed to discard disposable gowns immediately after use to stop the potential spread of any infections or diseases.
A review of the facility ' s policy titled Laundry and Bedding Soiled, revised on 10/2018, indicated soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Employees personal protective equipment, uniforms or clothing contaminated with blood or other potentially infectious materials are laundered, replaced or repaired at no cost to the employee.
A review of the Centers for Disease Control and Prevention (CDC) guidance, titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 9/23/2022, indicated the following:
1. The facility must stay connected with the healthcare-associated infection program in their state health department, as well as their local health department, and their notification requirements.
2. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction ' s public health authority.
3. The facility must ensure everyone is aware of recommended IPC practices in the facility by posting visual alerts, such as signs and posters, at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) These alerts should include instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can let help ensure people know that they reflect current recommendations.
4. Healthcare providers who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).
5. Management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures.
A review of the Los Angeles County Department of Public Health guidance, titled Coronavirus 2019: Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, dated 9/27/2022, indicated the following:
1. Facilities must regularly audit their HCP ' s adherence to appropriate PPE use.
2. Post appropriate Transmission-Based Precautions signage outside of each resident room.
3. Post signage on the appropriate steps for donning and doffing PPE in donning and doffing areas.
4. As part of standard precautions for all resident care, gloves should be changed between every resident encounter.
5. Gowns should be used for each resident encounter in Yellow and Red cohorts for COVID-19 precautions including in resident rooms, shower rooms, rehab gyms, and other areas where close contact may occur during resident care.
6. Gowns should be donned prior to entering and doffed prior to exiting resident care areas, which includes but are not limited to resident rooms and shared shower rooms. Gowns worn during close contact activities must be doffed prior to re-entering common areas, e.g., hallways.
7. Re-use (over multiple days) and extended use (over multiple residents) of gowns are not allowed.
d. During an observation on 11/10/2022, at 9 am, of an unannounced complaint investigation regarding a COVID-19 outbreak (a higher-than-expected number of occurrences of a disease in a specific location and time), the facility ' s main entrance to the building was observed without an Exposure Notice, indicating there was an active COVID-19 outbreak at the facility and what precautions needed to be followed upon entering and during their time at the facility.
During a concurrent observation and interview, on 11/10/2022 at 1:53 pm, with the facility ' s assigned Public Health Nurse (PHN) stated the Exposure Notice, emailed to the facility was not posted at the front entrance as instructed in the official COVID-19 Outbreak Letter. PHN stated, Exposure Notice, was to inform the staff and visitors what precautions were needed prior to entering and during their time at the facility to keep the residents safe.
During an interview on 11/10/2022 at 5:28 pm, the Administrator (ADM) stated the facility followed guidelines provided by the Centers for Medicare and Medicaid Services (CMS, federal agency that administers the nation's major healthcare programs), Center of Disease Control and Prevention (CDC, a U.S. federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability), and the local Public Health Agency.
During an observation and concurrent interview, on 12/7/2022 at 2:32 pm, with Infection Control Preventionist 1(IP 1) stated room [ROOM NUMBER] was considered a YZ room. IP 1 stated signage was missing to inform and remind staff and visitors on the type of PPE was needed and how to don (put on) and doff (take off) to prevent the spread of Covid-19.
During an interview on 12/8/2022 at 1:26 pm, Infection Preventionist 2 (IP 2) stated signage were important prior to entering a YZ room for staff to know the sequence of donning and doffing of PPE ' s.
A review of the facility ' s COVID-19 Outbreak Notification, dated 10/31/2022, from the facility ' s assigned Los Angeles County Public Health Nurse (PHN), indicated post exposure notice developed in consultation with Public Health at the entrance of the Facility and in communal areas.
A review of the facility ' s policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised on 4/2020, indicated the facility follows recommended standards and transmission-based precautions, environmental cleaning and social distancing practices to prevent the transmission of COVID-19 within the facility. Signage on the use of specific PPE (for staff) is posted in appropriate locations in the facility (e.g. outside of a resident ' s room, wing, or facility -wide.
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 F0886
(Tag F0886)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (minor to severe respiratory illness caused by a new vi...
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Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (minor to severe respiratory illness caused by a new virus called SARS-CoV-2 and spread from person to person) in accordance with the Public Health guidelines and the facility ' s policies and procedures by failing to ensure all staff were tested for COVID-19 with test results thoroughly documented in the facility ' s records
This deficient practice had the potential to further increase the spread of COVID-19 infection in the facility.
Findings:
On 12/7/2022 at 1:17 p.m., a follow-up complaint onsite visit related to infection control was conducted at the facility.
During an interview on 12/7/2022 at 1:26 p.m., in the presence of the local Outbreak Management Branch (OMB) team and Acute Communicable Disease Control (ACDC) team, Infection Preventionist 2 (IP 2) stated for this outbreak that started on 10/31/2022, COVID-19 PCR testing was being offered at the facility for all staff every Mondays, Wednesdays, and Fridays from 6:30 a.m. to 4 p.m. IP 2 stated all staff were supposed to be tested for COVID-19 at least every 3-7 days during the outbreak. IP 2 stated many staff would get screened for COVID-19 signs and symptoms, but they would skip the COVID-19 testing provided in-house by the contract laboratory would be allowed to work.
During an interview on 12/7/2022 at 1:35 p.m., in the presence of the local OMB and local ACDC teams, the Administrator stated she was aware that the facility was dealing with staff non-compliance with the COVID-19 testing requirements per public health guidance and regulations . The Administrator stated per the facility ' s most updated COVID-19 Mitigation Plan, staff who refuse COVID-19 testing must not be allowed to work in the facility unless compliance was achieved. The Administrator stated all staff will be notified in writing by 12/9/2022 that non-compliance to COVID-19 testing would result in immediate termination of the staff.
A review of the facility ' s Line Listing for the COVID-19 outbreak for the period 10/31/2022 to 12/8/2022 indicated the COVID-19 RT-PCR testing (test evaluated at a laboratory to detect the genetic material from a virus) results for the following sampled staff as of 12/7/2022:
a. Certified Nursing Assistant 1 (CNA 1) was unvaccinated and tested positive for COVID-19 on 8/26/2022, tested negative on 11/4/2022, but has not been tested again as of 12/7/2022.
b. CNA 2 tested for COVID-19 and was negative on 11/4/2022, 11/9/2022, 11/21/2022, and 11/28/2022.
c. CNA 4 tested for COVID-19 and was negative on 11/2/2022, 11/9/2022, 11/14/2022, 11/21/2022, and 12/5/2022.
d. CNA 5 tested for COVID-19 and was negative on 11/4/2022, 11/7/2022, 11/14/2022, 11/21/2022, 12/2/2022, and 12/7/2022.
e. CNA 6 tested for COVID-19 and was negative on 10/31/2022, 11/11/2022, 11/14/2022, 11/21/2022, 11/28/2022, and 12/5/2022.
f. Licensed Vocational Nurse 1 (LVN 1) tested for COVID-19 and was negative on 11/4/2022, 11/18/2022, 11/21/2022, and 11/28/2022.
g. LVN 2 tested for COVID-19 and was negative on 11/2/2022, 11/9/2022, 11/21/2022, 12/2/2022, and 12/7/2022.
A review of the timesheets for the period 10/31/2022 to 12/9/2022 of the sampled facility staff indicated staff worked on the following dates without any documented evidence of a negative COVID-19 testing as required by the public health guidelines:
a. CNA 1 worked on 11/25, 11/28, 11/29, 11/30, 12/1, 12/4, 12/5, and 12/6.
b. CNA 2 worked on 11/18, 11/19, 12/6, and 12/7.
c. CNA 4 worked on 11/29, 11/30, 12/1, and 12/4.
d. CNA 5 worked on 11/30 and 12/1.
e. CNA 6 worked on 11/8, 11/9, and 11/10.
f. LVN 1 worked on 11/12, 11/13, 11/17.
g. LVN 2 worked on 11/18, 11/19, 11/29, and 11/30.
During an interview on 12/8/2022 at 12:49 p.m., IP 2 stated prior to 12/7/2022, the facility did not perform onsite COVID-19 antigen tests (rapid tests that detect proteins called antigens from the SARS-CoV-2 virus and produce results in 15-30 minutes). IP 2 stated the facility did not obtain documented evidence of the COVID-19 testing of all staff, including contractual staff, done outside the facility. IP 2 stated it was important to conduct timely COVID-19 testing to prevent transmission of the COVID-19 infection.
During a telephone interview on 12/12/2022 at 12:07 p.m., Medical Doctor 1 (MD 1) stated although he was employed by Healthcare Company 1 (HC 1), which has a contractual agreement with the facility, he would conduct resident visits at the facility almost daily during weekdays. MD 1 stated with regard to COVID-19 testing, there has been a lot of variations that happened since the outbreak started. MD 1 stated the facility recently conducted antigen tests onsite for all staff last week and would conduct PCR tests starting this week. MD 1 stated prior to last week, he did either saliva testing (genetic testing of saliva samples to detect the COVID-19 virus) at HC 1 or performed at-home testing, but he was not required by the facility to provide documentation of the COVID-19 test results prior to his onsite visits at the facility.
A review of the facility ' s document titled COVID-19 Mitigation and Testing Plan, updated on 8/25/2022, indicated the following:
1. Objectives of the Mitigation and Testing Plan include maintaining a safe and secure environment for residents, staff, and visitors; getting testing for residents and staff within a clinical valuable timeframe in a way that respects their right to choose whether or not to be tested, and designating space that can be safely used to isolate COVID+ residents without posing a risk to the life and safety of other residents or staff.
2. With regard to response testing, the following procedures were developed:
a. If a single positive COVID-19 case is identified among either staff or residents, the SNF must conduct comprehensive testing of all residents and staff regardless of vaccination status to identify potential asymptomatic infections.
b. All residents and staff should be tested on ce every 3-7 days.
c. All residents and staff who test negative must be included in response testing until there are at least 2 weeks with no additional infections identified.
3. For staff refusing COVID-19 testing, the following restrictions apply to staff directly employed by the facility:
a. Staff who have signs or symptoms of COVID-19 and refuse testing must be prohibited from entering the facility until return-to-work criteria are met.
b. If outbreak testing has been triggered and a staff member refuses testing, the staff member must be restricted from entering the facility until the outbreak has been closed.
c. Facility must document any staff refusing to take a COVID-19 test and place these individuals off the schedule for failure to comply with County Guidelines until they test and have a negative result via antigen or PCR testing.
A review of the Centers for Disease Control and Prevention (CDC) guidelines, titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19 Pandemic), updated on 9/23/2022, indicated the following:
1. Healthcare facilities responding to SARS-CoV-2 transmission within the facility must always notify and follow the recommendations of public health authorities.
2. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction ' s public health authority.
3. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts could not be identified or managed with contact tracing or if contact tracing failed to halt transmission.
[Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html]
In addition, a review of the CDC guidelines, titled Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, updated on 9/23/2022, indicated the following:
1. Following a higher-risk exposure, HCP should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This would typically be at day 1 (where day of exposure is day 0), day 3, and day 5.
2. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of NAAT is recommended.
[Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html]
A review of the local county ' s Department of Public Health (DPH) guidelines titled, Coronavirus 2019: Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, updated on 9/27/2022 (current at the time of onsite visit), indicated the following:
1. If a single positive COVID-19 case is identified among either staff or residents, the SNF must conduct comprehensive testing of all residents and staff regardless of vaccination status to identify potential asymptomatic infections.
2. All residents and staff should be tested on ce every 3-7 days.
3. Individuals who are asymptomatic, close contacts or exposed, and within 31-90 days of recent COVID-19 infection, then point-of-care antigen tests are preferred over molecular tests, e.g., RT-PCR. All residents and staff who test negative must be included in response testing until there are at least 2 weeks with no additional infections identified.
4. With regard to staff refusing COVID-19 testing, the following restrictions apply to staff directly employed by the facility:
a. Staff who have signs or symptoms of COVID-19 and refuse testing must be prohibited from entering the facility until return-to-work criteria are met.
b. If outbreak testing has been triggered and a staff member refuses testing, the staff member must be restricted from entering the facility until the outbreak has been closed.
[Source: http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/prevention/]
May 2021
26 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0688
(Tag F0688)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide range of motion exercises (activity aimed at ...
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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 range of motion exercises (activity aimed at improving movement of a specific joint, a point where two bones make contact) to 11 of 12 sampled residents (Resident 75, 183, 91, 167, 146, 27, 136, 163, 151, 40, and 103) as indicated in the facility's Rehabilitative (helping to restore to good condition) Nursing Care policy.
This deficient practice resulted for Resident 75 to experience pain and decline in mobility that caused severe contractures (deformity and joint stiffness) of the resident's right hand and both legs.
Findings:
Cross reference F656, F686, and F725
a. A review of Resident 75's Face Sheet (admission Record) indicated the facility admitted Resident 75 on 4/19/2019 and readmitted the resident on 11/15/2019 from a general acute care hospital (GACH) with diagnoses of right intertrochanteric femur fracture (broken hip), dementia (loss of memory and other mental abilities severe enough to interfere with daily life), and history of falling
A review of Resident 75's Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]), Evaluation and Plan of Treatment, dated 11/16/2019, indicated Resident 75's right arm range of motion (ROM, the full movement potential of a joint) was within normal limits (normal joint movement). The OT Evaluation document indicated Resident 75's left arm ROM was within functional limits (sufficient joint movement to functionally complete daily routines) and the resident's left shoulder had limited motion.
A review of Resident 75's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 11/16/2019, indicated Resident 75's ROM in both legs were within functional limits.
A review of Resident 75's Rehabilitation Functional ROM and Voluntary Movement Screen, dated 2/15/2020, indicated Resident 75 had no ROM limitations in both legs and both hands.
A review of Resident 75's OT Discharge summary, dated [DATE], indicated Resident 75 was discharged with recommendations for a Restorative Range of Motion Program (to restore as much independence as possible and/or prevent decline in function) for both arms.
A review of Resident 75's PT Discharge summary, dated [DATE], indicated a Restorative Program was not indicated for Resident 75's legs because Resident 75 was transferred to hospice care (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure).
A review of Resident 75's Physician's Orders, dated 2/22/2020, indicated for the resident to receive Restorative Nursing Assistant (RNA, nursing aide program that helps residents maintain their function and joint mobility) services and to provide Resident 75 with passive range of motion (PROM, amount of motion at a given joint when the joint is moved by an external force or by a therapist) exercises on both arms five days a week as tolerated by the resident.
During an interview on 5/4/2021, at 8:42 a.m., Director of Rehabilitation (DOR) stated therapists provided education to RNA staff prior to transitioning residents to RNA services.
A review of Resident 75's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 2/25/2020 indicated Resident 75 was moderately impaired with cognitive (thinking and memory) skills for daily decision making. The MDS indicated Resident 75 had clear speech, usually expressed ideas and wants, and understood others. The MDS indicated Resident 75 did not have any limitations in functional ROM in both arms and legs.
A review of Resident 75's care plan titled, Activities of Daily Living Deficit, dated 2/25/2021, indicated the interventions were to provide ROM exercises to the resident.
A review of Resident 75's RNA Flow Sheets indicated Resident 75 received range of motion exercises to both arms in 2/2020 and 4/2020.
A review of Resident 75's Physician's Orders dated 9/18/2020 indicated to discontinue Resident 75's RNA program.
A review of Resident 75's Joint Mobility Assessment, dated 5/14/2020, 8/12/2020, and 11/11/2020, indicated minimum loss of ROM (25-50%) on Resident 75's right hip and right knee and moderate loss of motion (60-75%) on the left shoulder.
A review of Resident 75's Joint Mobility Assessment, dated 2/20/2021, indicated the resident had moderate loss of ROM on Resident 75's left shoulder, both hips and both ankles. The Joint Mobility Assessment indicated Resident 75 had severe loss of motion (75-100%) on Resident 75's right hand, right fingers, and right knee.
During an observation on 5/3/2021 at 12:40 pm, inside Resident 75's room, Resident 75 was lying in bed. Resident 75's right leg crossed midline over the left leg and dangled over the left side of the bed. Resident 75's left leg was crossed underneath the right leg with the left hip positioned in external rotation (hip rotated away from the body) and knee bent. Resident 75's left leg position resembled sitting on the floor with legs crossed in front of the body. Resident 75 complained of left leg pain.
During an interview on 5/4/2021 at 2:49 pm, Certified Nursing Assistant 6 (CNA 6) stated the Resident 75's legs were always crossed.
During an interview on 5/5/2021 at 8:53 am, Licensed Vocational Nurse 8 (LVN 8) stated both of Resident 75's legs were contracted (deformed with joint stiffness). LVN 8 stated it was difficult to turn the resident to either side since Resident 75 screamed from discomfort.
During an interview on 5/6/2021, at 11:59 am, MDS Nurse 2 (MDS 2) stated if there was no RNA Flow Sheet in the clinical record, then the resident was not seen for RNA exercises.
During an interview on 5/6/2021, at 3:54 p.m., Occupational Therapist 1 (OT 1) stated Resident 75 was able to sit in a wheelchair for activities of daily living, like hygiene, grooming, and lower body dressing. OT 1 stated that she recommended a Restorative Nursing Program for Resident 75 to maintain ROM to both arms since Resident 75 was a long-term care resident with limited cognition, making Resident 75 at risk for developing contractures.
During an interview on 5/6/2021, at 4:24 p.m., the facility's Director of Nursing (DON) stated residents on hospice care such as Resident 75, should continue to receive basic nursing care while residing in the facility, which included but was not limited to hygiene, feeding, activities, medication administration, and mobility.
During an observation on 5/7/2021, at 7:55 am, in Resident 75's room, Resident 75 was eating using the left hand to hold onto a bowl while the right-hand thumb and index finger held the utensil. Resident 75's right-hand middle, ring, and small fingers were observed in a flexed position.
During an observation and concurrent interview on 5/7/2021, at 7:59 am, in Resident 75's room, LVN 8 was unable to extend Resident 75's right hand middle, ring, and small fingers which were in a flexed (bent) position touching the right palm. Resident 75 expressed pain upon LVN 8's attempts to extend the fingers. LVN 8 then repositioned Resident 75's legs. Resident 75 became tearful and stated that the left leg was painful. LVN 8 stated Resident 75 did not like to be turned due to the contractures in both legs.
During an interview on 5/7/2021, at 9:57 am, Director of Rehabilitation (DOR) stated Resident 75's ROM further declined on 2/20/2021 as compared to the assessment on 11/11/2020.
During an interview on 5/7/2021, at 10:58 am, the DON stated restorative nursing care was a continuation of nursing care for residents to maintain mobility and maximize function. DON stated restorative nursing care did not exclude hospice residents. DON stated Resident 75's contractures were avoidable as the facility failed to provide any restorative nursing care for range of motion.
During an interview on 5/7/2021, at 12:05 pm, Medical Records 2 (MR 2) stated she was unable to locate Resident 75's RNA Flow Sheets for PROM exercises on both arms for 3/2020, 5/2020, 6/2020, 7/2020, 8/2020 and 9/2020.
A review of the facility's policy titled, Rehabilitative Nursing Care, with a revised date of 7/2013, indicated the facility's rehabilitation nursing care program was designed to assist each resident to achieve and maintain an optimal level of self-care and independence. The policy indicated the program included assisting residents to carry out prescribed therapy exercises.
b. A review of Resident 183's Face Sheet indicated Resident 183 was re-admitted to the facility on [DATE]. Resident 183's diagnoses included were chronic respiratory failure (airways carrying air to lungs become narrow and damaged, limiting air movement in the body), pressure ulcer (bed sore) of right buttock, left hip, sacral (tail bone) region, right heel, and left heel, and attention to tracheostomy (hole that surgeons make through the front of the neck and into the windpipe (trachea) to allow air into the lungs).
A review of Resident 183's MDS, dated [DATE], indicated Resident 183's cognition was intact. Resident 183 required total assistance with bed mobility, transfers, dressing, and hygiene. The MDS indicated Resident 183 had functional ROM limitations on both arm and both legs.
A review of Resident 183's Physician's Orders, dated 6/30/20, indicated for RNA to provide gentle PROM on both arms and legs, five times per week or as tolerated. It also indicated to apply bilateral (both sides) ankle foot orthosis (AFO, brace to hold the foot and ankle in the correct position) for both legs, five times per week for four to six hours or as tolerated.
A review of Resident 183's Restorative Record, dated 4/2021, indicated the following dates with an X and blank dates: 4/3/21, 4/4/21, 4/5/21, 4/6/21, 4/10/21, 4/11/21, 4/17/21, 4/18/21, 4/20/21, 4/23/21, 4/24/21, 4/25/21, 4/29/21, and 4/30/21.
During an interview on 5/4/21, at 8:42 am, RNA 1 stated a blank date in a resident's Restorative Record indicated the resident was not seen that day for RNA.
During an interview on 5/6/21 at 12:24 pm, RNA 4 stated an X on the Restorative Record indicated the resident was not seen for RNA services on that specific date or dates.
During an interview on 5/6/21 at 12:50 pm, MDS 2 stated Resident 183 was not seen for RNA per physician's order on 4/3/21, 4/4/21, 4/5/21, 4/6/21, 4/10/21, 4/11/21, 4/17/21, 4/18/21, 4/20/21, 4/23/21, 4/24/21, 4/25/21, 4/29/21, and 4/30/21 since the RNA staff were pulled to perform Certified Nursing Assistant duties. MDS 2 stated residents could develop contractures without the provision of RNA services.
c. A review of Resident 91's Face Sheet indicated Resident 91 was re-admitted to the facility on [DATE]. Resident 91's diagnoses included were chronic respiratory failure heart failure (), and muscle wasting.
A review of Resident 91's MDS, dated [DATE], indicated Resident 91's cognition was intact. Resident 91 required extensive assistance with bed mobility, transfers, and hygiene. The MDS indicated Resident 91 had functional ROM limitations on both arms and both legs.
A review of Resident 91's Physician's Orders, dated 12/21/20, indicated for RNA to provide active assistive range of motion (AAROM, movement of a joint of limb in which the person provides some effort but also receives some assistance from an outside force) exercises on both legs, five days per week or as tolerated.
A review of Resident 91's Physician's Orders, dated 2/25/20, indicated for RNA to provide AAROM exercises on both arms, five days per week or as tolerated.
During an observation on 5/6/21 at 9:10 am, Resident 91 moved both arms, but complained of left shoulder pain.
During an interview on 5/6/21, at 9:33 am, RNA 3 stated a blank date in a resident's Restorative Record indicated the resident was not seen for RNA. RNA stated Resident 91 needs to be medicated prior to RNA exercises. RNA 3 stated Resident 91 can develop contractures and further pain if not seen for RNA exercises.
A review of Resident 91's Restorative Record for 4/2021 indicated the following blank dates: 4/1/21, 4/2/21, 4/3/21, 4/4/21, 4/5/21, 4/7/21, 4/8/21, 4/9/21, 4/13/21, 4/14/21, 4/25/21, 4/26/21, 4/27/21, and 4/30/21.
A review of Resident 91's Restorative Record for 5/2021 indicated the following blank dates: 5/1/21, 5/2/21, and 5/4/21.
During an interview on 5/6/21, at 9:33 am, RNA 3 stated Resident 91 was not seen on 5/4/21 since it was RNA 3's day off. In a follow-up interview on 5/6/21 at 10:02 am, RNA 3 stated Resident 91 was not seen per physician's orders in 4/2021 due to staffing shortage. RNA 3 stated that RNA staff were pulled to perform Certified Nursing Assistant duties.
d. A review of Resident 167's Face Sheet indicated Resident 167 was re-admitted to the facility on [DATE]. Resident 167's diagnoses included were hemiplegia (weakness on one side of the body) following a cerebral infarct (damage to tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side.
A review of Resident 167's MDS, dated [DATE], indicated Resident 167's cognition was intact. Resident 167 required limited assistance with bed mobility and transfers, and required extensive assistance with dressing. The MDS indicated Resident 167 had functional ROM limitations on one arm.
A review of Resident 167's Physician's Orders, dated 4/13/21, indicated for RNA to provide PROM exercises on left arm, five days per week as tolerated and to apply and remove left hand splint (material used to restrict, protect, or immobilize a part of the body to support function, assist, and/or increase range of motion) for 4-6 hours, five days per week as tolerated.
A review of Resident 167's Physician's Orders, dated 4/19/21, indicated for RNA to provide ambulation (walking) using hemi-walker (small, one-handed walker intended to be used for residents whose one half of their body is weakened), five days per week as tolerated.
During an observation and interview on 5/3/21, at 10:35 am, Resident 167 was observed with left sided weakness and was not wearing a splint. stated Resident 167 was supposed to receive ROM exercises and wear a splint to the left arm. Resident 167 denied receiving any ROM exercises and stated the splint was not applied.
A review of Resident 167's Restorative Record for April 2021 was completely blank.
During an interview on 5/6/21, at 9:33 a.m., RNA 3 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA.
During an interview on 5/6/21, at 11:59 a.m., MDS 2 stated Resident 167 was not seen for RNA per physician's order since the RNA staff were pulled to perform Certified Nursing Assistant duties in 4/2021. MDS 2 stated residents could develop contractures without the provision of RNA services.
e. A review of Resident 146's Face Sheet indicated Resident 146 was admitted to the facility on [DATE]. Resident 146's diagnoses included but was not limited to chronic respiratory failure (airways carrying air to lungs become narrow and damaged, limiting air movement in the body), heart valve replacement, muscle wasting, and attention to tracheostomy (hole that surgeons make through the front of the neck and into the windpipe [trachea] to allow air into the lungs).
A review of Resident 146's MDS, dated [DATE], indicated Resident 146 was severely impaired with daily decision making, required extensive assistance with bed mobility and dressing, and required total assistance with transfers and eating. The MDS indicated Resident 146 had functional range of motion (ROM) limitations in one arm and one leg.
A review of Resident 146's Physician's Orders, dated 4/28/21, indicated for RNA to provide gentle PROM on both legs, five days per week or as tolerated, and PROM on both arms, five days per week or as tolerated.
During an interview on 5/6/21, at 11:59 a.m., MDS 2 stated was unable to locate Resident 146's Restorative Record for April and May 2021. MDS 2 stated Resident 146 was not seen for RNA exercises since 4/29/21.
f. A review of Resident 27's Face Sheet indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's diagnoses included but was not limited to spinal stenosis (narrowing) in the lumbar (lower back) region.
A review of Resident 27's MDS, dated [DATE], indicated Resident 27's cognition was intact, was independent with eating, and required limited assistance for dressing. The MDS indicated Resident 27 had functional range of motion limitations in both legs.
During an observation and interview on 5/3/21, at 11:30 a.m., Resident 27 was observed with contractures to both legs. Resident 27 stated Resident 27 was supposed to receive range of motion exercises three times per week. Resident 27 denied receiving exercises.
A review of Resident 27's Physician's Orders, dated 3/9/17, indicated for RNA to provide active assisted range of motion (AAROM, movement of a joint of limb in which the person provides some effort but also receives some assistance from an outside force) to both arms, 3 times per week and PROM to both legs, 3 times per week. Further review of Resident 27's Physician's Orders, dated 10/17/19, indicated for RNA to apply both ankle foot orthoses (AFO - brace to hold the foot and ankle in the correct position), 3 times for week for 4-6 hours or as tolerated.
During an interview on 5/6/21, at 9:33 a.m., RNA 3 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA.
A review of Resident 27's Restorative Record for April 2021 indicated blank dates on 4/1/21, 4/2/21, 4/3/21, 4/4/21, 4/5/21, 4/6/21, and 4/7/21.
During an interview on 5/6/21, at 11:59 a.m., MDS 2 stated Resident 27 was not seen for RNA per physician's order since the RNA staff were pulled to perform Certified Nursing Assistant duties in April 2021. MDS 2 stated residents could develop contractures without the provision of RNA services.
g. A review of Resident 136's Face Sheet indicated Resident 136 was admitted to the facility on [DATE] with diagnoses including but not limited to heart disease, morbid (severe) obesity, and chronic embolism (blot clot).
A review of Resident 136's MDS, dated [DATE], indicated Resident 136 was moderately impaired for daily decision making and required total assistance for bed mobility, transfers, dressing, hygiene, and eating.
During an observation on 5/3/21 at 10:26 a.m., Resident 136 was lying in bed with the right arm positioned into shoulder internal rotation (rotated toward the body), elbow bent, wrist bent down, and fingers bent at the knuckles. Resident 136 was not wearing a splint (material used to restrict, protect, or immobilize a part of the body to support function, assist, and/or increase range of motion) on the right arm.
A review of Resident 136's Physician's Orders indicated for RNA to provide the following:
- 10/16/19: PROM to both legs, five times per week as tolerated.
- 10/17/19: PROM to the right arm, five times per week as tolerated.
- 2/3/20: RNA to apply right elbow splint, five times per week for 4-6 hours or as tolerated.
- 12/19/20: PROM exercises to right arm, five times per week as tolerated.
- 12/19/20: Apply right elbow splint for 4-6 hours, five times per week as tolerated.
- 12/21/20: Gentle PROM on right leg, five times per week or as tolerated.
- 12/21/20: Gentle active assistive range of motion (AAROM, movement of a joint of limb in which the person provides some effort but also receives some assistance from an outside force) on left leg, five times per week or as tolerated.
During an interview on 5/4/21, at 9:25 am, RNA 2 stated there were 89 residents that received RNA services. During a follow-up interview on 5/4/21, at 10:59 a.m., RNA 2 stated Resident 136 was not seen for RNA on 5/3/21 since there was only one RNA staff. RNA 2 stated that residents could develop contractures and experience a decline in function without the provision of RNA services.
During an interview on 5/6/21, at 9:33 a.m., RNA 3 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA.
A review of Resident 136's Restorative Record for April 2021 indicated the following blank dates: 4/1/21, 4/2/21, 4/3/21, 4/4/21, 4/5/21, 4/6/21, 4/7/21, 4/8/21, 4/9/21, 4/10/21, 4/12/21, 4/13/21, 4/14/21, 4/16/21, 4/18/21, 4/19/21, 4/20/21, 4/21/21, 4/22/21, 4/23/21, 4/24/21, 4/25/21, 4/26/21, 4/27/21, 4/29/21, and 4/30/21.
During an interview on 5/6/21, at 11:59 a.m., MDS 2 stated residents were not seen for RNA per physician's order since the RNA staff were pulled to perform Certified Nursing Assistant duties in April 2021. MDS 2 stated residents could develop contractures without the provision of RNA services.
h. A review of Resident 163's Face Sheet indicated Resident 163 was re-admitted on [DATE] with diagnoses on pneumonia, heart failure, and pressure ulcer (bed sore) of the sacral (tail bone) region.
A review of Resident 163's MDS, dated [DATE] indicated Resident 163 was severely impaired for daily decision making and required total assistance for bed mobility, transfers, dressing, and hygiene. The MDS indicated Resident 163 had functional range of motion limitations in both arms and both legs.
A review of Resident 163's Physician's Orders, dated 4/27/21, indicated for RNA to provide PROM to both legs, five days per week as tolerated. Resident 163's Physician's Orders, dated 4/27/21 also indicated for RNA to provide AAROM to both arms, five days per week as tolerated.
During an interview on 5/4/21, at 9:25 am, RNA 2 stated there were 89 residents that received RNA services. During a follow-up interview on 5/4/21, at 10:59 a.m., RNA 2 stated residents in Stations 1 and 3, including Resident 163, were not seen for RNA on 5/3/21 since there was only one RNA staff. RNA 2 stated that residents could develop contractures and experience a decline in function without the provision of RNA services.
A review of Resident 163's Restorative Record for May 2021 indicated the following blank dates: 5/1/21, 5/2/21, and 5/3/21.
During an interview on 5/6/21, at 9:33 a.m., RNA 3 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA.
i. A review of Resident 151's Face Sheet indicated Resident 151 was re-admitted to the facility on [DATE] with diagnoses including but not limited to Guillain-Barre syndrome (rare disorder in which the body's immune system attacks the nerves, eventually paralyzing the body) and chronic respiratory failure (airways carrying air to lungs become narrow and damaged, limiting air movement in the body).
A review of Resident 151's MDS, dated [DATE], indicated Resident 151's cognition was intact but required total assistance for bed mobility, dressing, eating, and hygiene. The MDS indicated Resident 151 had functional limitations in range of motion in both legs.
During an observation and interview on 5/3/21 at 10:30 a.m., Resident 151 was lying in bed and observed with weakness and contractures in both arms. Resident 151 denied receiving consistent range of motion exercises.
A review of Resident 151's Physician's Orders, dated 1/16/21, indicated for RNA to provide PROM exercises in both arms, five days per week as tolerated, and PROM exercises in both legs, five days per week as tolerated.
During an interview on 5/4/21, at 8:42 a.m., RNA 1 stated that a blank date in a resident's Restorative Record indicated that the During an interview on 5/4/21, at 8:42 a.m., RNA 1 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA. RNA 1 stated there were 40 residents in the facility's subacute area that received RNA. RNA 1 was the only RNA staff on 5/3/21 and unable to perform RNA exercises with 24 subacute residents, including Resident 151.
During an interview on 5/6/21 at 12:24 p.m., RNA 4 stated putting an X on the Restorative Records for the dates the resident was not seen for RNA.
A review of Resident 151's Restorative Record for April 2021 indicated the following dates with an X and blank dates: 4/3/21, 4/4/21, 4/9/21, 4/10/21, 4/11/21, 4/12/21, 4/13/21, 4/16/21, 4/17/21, 4/18/21, 4/20/21, 4/21/21, 4/25/21, 4/27/21, and 4/28/21.
A review of Resident 151's Restorative Record for May 2021 indicated the following dates with an X and blank dates: 5/1/21, 5/2/21, and 5/3/21.
During an interview on 5/6/21, at 11:59 a.m., MDS 2 stated residents could develop contractures without the provision of RNA services.
j. A review of Resident 40's Face Sheet indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including but not limited to chronic respiratory failure (airways carrying air to lungs become narrow and damaged, limiting air movement in the body), chronic kidney disease, and weakness.
A review of Resident 40's MDS, dated [DATE], indicated Resident 40 cognition was moderately impaired for daily decision making and required total assistance for transfers, bed mobility, hygiene, dressing, and bathing. The MDS indicated Resident 40 had functional range of motion limitations in both legs.
A review of Resident 40's Physician's Orders, dated 4/30/21, indicated for RNA to provide AROM to both arms, five days per week as tolerated. Further review of Resident 40's Physician's Orders, dated 5/4/21, indicated for RNA to provide AAROM to both legs, five days per week as tolerated.
During an interview on 5/4/21 at 1:31 p.m., Resident 40 stated feeling stronger but needed more exercises. Resident 40 stated Resident 40 received exercises every three days for five minutes.
During an interview on 5/4/21, at 8:42 a.m., RNA 1 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA. RNA 1 stated there were 40 residents in the facility's subacute area that received RNA. RNA 1 was the only RNA staff on 5/3/21 was unable to perform RNA exercises 24 subacute residents, including Resident 40.
A review of Resident 40's Restorative Record for May 2021 indicated the following blank dates for RNA to provide AROM to both arms: 5/1/21, 5/2/21, 5/3/21, 5/4/21, and 5/5/21.
A review of Resident 40's Restorative Record for May 2021 indiated the following blank dates for RNA to provide AAROM to both legs: 5/4/21 and 5/5/21.
k. A review of Resident 103's Face Sheet indicated Resident 103 was re-admitted to the facility on [DATE] with diagnoses including but not limited to abscess (painful collection of pus, usually caused by a bacterial infection) of the right lower limb, hemiplegia (weakness on one side of the body) following cerebral infarct (damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, aphasia (difficulty communicating) following cerebral infarct, and dysphagia (difficulty swallowing).
A review of Resident 103's MDS, dated [DATE], indicated Resident 103 was severely impaired for daily decision making and required total assistance for bed mobility, transfers, dressing, and bathing. The MDS indicated Resident 103 had functional range of motion limitations in both arms and both legs.
A review of Resident 103's Physician Orders, dated 2/10/21, indicated for RNA to provide the following:
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Both knee splints (material used to restrict, protect, or immobilize a part of the body to support function, assist, and/or increase range of motion), five times per week for 4-6 hours per day or as tolerated.
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Gentle PROM on both arms, five times per week or as tolerated.
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Right grip hand splint 4-6 hours per day, five times per week or as tolerated.
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PROM to both legs, five times per week or as tolerated.
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Apply right elbow extension split 4-6 hours per day, five times per week or as tolerated.
During an interview on 5/4/21, at 9:25 am, RNA 2 stated there were 89 residents that received RNA services in the facility's skilled nursing area. During a follow-up interview on 5/4/21, at 10:59 a.m., RNA 2 stated residents in Stations 1 and 3, including Resident 103, were not seen for RNA on 5/3/21 since there was only one RNA staff. RNA 2 stated that residents could develop contractures and experience a decline in function without the provision of RNA services.
During an interview on 5/6/21, at 9:33 a.m., RNA 3 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA.
A review of Resident 103's Restorative Record for April 2021 indicated the following blank dates: 4/1/21, 4/2/21, 4/4/21, 4/6/21, 4/7/21, 4/8/21, 4/9/21, 4/10/21, 4/11/21, 4/12/21, 4/13/21, 4/14/21, 4/17/21, 4/19/21, 4/20/21, 4/21/21, 4/22/21, 4/23/21, 4/25/21, 4/26/21, 4/29/21, and 4/30/21.
A review of Resident 103's Restorative Record for May 2021 indicated the following blank dates: 5/1/21, 5/2/21, and 5/3/21.
During an interview on 5/6/21, at 11:59 a.m., MDS 2 stated RNA staff were pulled to perform Certified Nursing Assistant duties in April 2021. MDS 2 stated residents could develop contractures without the provision of RNA services.
A review of the facility's policy entitled, Rehabilitative Nursing Care revised July 2013, indicated that the facility's rehabilitation nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. The program included assisting residents to carry out prescribed therapy exercises.
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 an environment that promoted the dignity and respect during meals for one of 35 sampled residents (Resident 75) as in...
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Based on observation, interview, and record review, the facility failed to provide an environment that promoted the dignity and respect during meals for one of 35 sampled residents (Resident 75) as indicated in the facility's policy and procedure.
This deficient practice had the potential to negatively impact the resident's psychosocial well-being.
Findings:
A review of Resident 75's Face Sheet (admission Record) indicated the facility admitted Resident 75 on 4/19/2019 and readmitted the resident on 11/15/2019 from a general acute care hospital (GACH) with diagnoses of right intertrochanteric femur fracture (broken hip), dementia (loss of memory and other mental abilities severe enough to interfere with daily life), and history of falling
A review of Resident 75's Minimum Data Set (MDS, a comprehensive care planning tool), dated 2/18/2021, indicated Resident 75 was totally dependent for eating and required one person to assist.
During an observation on 5/3/2021, at 12:33 p.m., Resident 75 was eating lunch while lying in bed with the head of bed elevated. Certified Nursing Assistant 5 (CNA 5) was feeding Resident 75 while standing to the right side and behind the resident. The height of CNA 5's face was approximately two-feet above Resident 75.
During an interview on 5/4/2021, at 8:32 a.m., the facility's Director of Staff Development (DSD) stated the facility staff who assisted any residents with feeding including Resident 75, were supposed to sit at eye level which was important for communication and safety to prevent choking.
During an interview on 5/4/2021 at 9:06 a.m., DSD stated the facility did not have a written policy and procedure for feeding residents who needed assistance.
A review of the undated nursing assisting skill competency, titled Feeding a Resident, indicated to Sit down next to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure that a resident with an indwelling catheter (known as Foley catheter, a tube that allows urine to drain from the bladde...
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Based on observation, interview and record review, the facility failed to ensure that a resident with an indwelling catheter (known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) tubing was not kinked for one of one sampled resident (Resident 183).
This deficient practice had the potential to result in recurrence of urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) that could to lead to urosepsis (a potentially life-threatening complication of urinary tract infection).
Findings:
A review of Resident 183's Facesheet (admission Record) indicated the facility readmitted Resident 183 on 6/29/20. Resident 183's diagnoses included neuromuscular dysfunction of bladder (also known as neurogenic bladder, condition in which problems with the nervous system affect the bladder and urination, dysphagia (difficulty swallowing), and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood).
A review of Resident 183's Physician's order, dated 6/29/20 indicated for staff to start Foley catheter, french 18/10cc, attached to bedside drainage bag every shift for neurogenic bladder.
A review of Resident 183's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 4/5/21 indicated the resident's cognitive skills (ability to think and process information) for daily decision making was intact. The MDS indicated Resident 183 required total dependence from staff for bed mobility, dressing, eating, toilet use and personal hygiene.
During an observation on 5/3/21, at 9:49 AM, with Registered Nurse 6 (RN 6), Resident 183's foley catheter tubing was kinked. RN 6 released the foley catheter and to allow the urine to flow down the tubing into the urine bag. A concurrent interview was conducted; RN 6 stated it was important that the foley catheter should be free of kinks so that the urine output will be flowing freely to prevent back flow of the urine and not cause urine infection and to prevent urinary distension.
During an interview on 5/6/21, at 11:23 AM, the Director of Nursing (DON) stated the foley catheter tubing should not be kinked. The DON stated when the foley catheter kinked the urine will go back up in the bladder it could cause spasms and discomfort to the resident. The DON stated foley catheter tubing should be draining and patent all the time.
A review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revised on September 2014, indicated for staff to check the resident frequently to be sure the is not lying on the catheter and to keep the catheter and tubing free of kinks.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure staff assessed and placed dressing on hemodialysis catheter (hallow tube inserted into a large vein for exchanging bloo...
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Based on observation, interview and record review, the facility failed to ensure staff assessed and placed dressing on hemodialysis catheter (hallow tube inserted into a large vein for exchanging blood to and from a blood filtering machine and a patient) access site for one of three residents (Resident 103).
This failure place Resident 103 at risk for developing an infection of the skin where the hemodialysis catheter is inserted or infection of the blood stream.
Findings:
During an observation on 5/4/21, at 8:00 AM in Resident 103's room, Residents 103's right chest hemodialysis catheter had no dressing over the insertion site. Insertion site is dry and crusted, no redness, swelling or drainage noted.
During an interview on 5/4/21, at 12:20 PM LVN 1 stated, there should be Dressing on Resident 103's hemodialysis catheter. LVN 1 stated the resident had dialysis yesterday and dialysis nurses were supposed to put the dressing on the catheter insertion site. LVN 1 stated she will put one on now, so the resident would not get infection at the site.
During a concurrent observation and interview on 5/4/21, at 1:28 PM, Resident 103's hemodialysis catheter has dressing over insertion site. LVN 1 stated, the dressing was not on the site when the resident came back from dialysis. LVN 1 stated she didn't notice this morning that the resident did not have the dressing on. LVI 1 state she did not check Resident 103's hemodialysis catheter site.
During a review of the facility's policy and procedure (P&P) titled, Hemodialysis Access Care, dated 2010, the P&P indicated that the dressing change is done in the dialysis center post-treatment. The policy indicated if dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure.
A record review of Resident 103's Central Venous Catheter (CVC)/Permcath (a type catheter used for hemodialysis) After Instructions, undated, indicated there should be a dressing on the chest as long as the catheter is in place.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure the nurse staffing information on the posting was accurate for 3 of 5 days (5/3/21, 5/4/21, 5/5/21).
This deficient pra...
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Based on observation, interview and record review, the facility failed to ensure the nurse staffing information on the posting was accurate for 3 of 5 days (5/3/21, 5/4/21, 5/5/21).
This deficient practice had the potential to result in misinformation to the residents and the public regarding the facility's nursing staffing data.
Findings:
During an observation with Registered Nurse 6 (RN 6), on 5/3/21 at 2:12 PM, a daily nurse staffing information was posted by the sub-acute nursing station, and next to the entrance of the front lobby.
During a review of the actual staffing sign in sheet on 5/3/21, at 3:01 PM with Director of Staff Development (DSD 1), the nurse staffing information and the actual staffing sign in sheet for the staff who worked reflected the following:
1.
On 5/3/21 for the 11 PM to 7 AM shift, there were 16 certified nurse assistants (CNAs) on the nursing staffing posting while the sign in sheet reflected 14 CNAs.
2.
On 5/4/21 for the 7 AM to 3 PM shift, there were 19.2 CNAs on the nursing staffing posting while the sign in sheet reflected 15 CNAs.
3.
On 5/5/21 for the 11 PM to 7 AM shift, there were 15.5 CNAs on the nursing staffing posting while the sign in sheet reflected 12 CNAs.
During an interview, on 5/5/21 at 3:10 PM, DSD 1 stated the daily staff posting on 5/3/21, 5/4/21, 5/5/21 should be based on the number of staff working and hours every shift. DSD 1 stated it was important that the daily posting was correct for the visitors and family members to know who and how many people worked and provided care to the resident.
During a review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, dated August 2006, the P&P, indicated within two hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPN's and LVNs) and the number of unlicensed nursing personnel (CNA's) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.
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** b. A review of Resident 710's Face Sheet (admission Record), indicated the facility admitted the resident on 5/3/21 with diagnos...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 710's Face Sheet (admission Record), indicated the facility admitted the resident on 5/3/21 with diagnoses of osteomyelitis (bone infection), pressure ulcers (areas of damaged skin caused by staying in one position for too long), and anxiety disorder (a mental health disorder that involves extreme fear or worry).
A review of Resident 710's Physician Orders for the month of May 2021, indicated for the resident to receive Diazepam (medication the treat anxiety), 5 milligrams, every eight hours as needed for anxiety.
A review of Resident 710's Record of Controlled Substances (RCS), indicated Resident 710 received Diazepam on 5/5/21 at 9:30 p.m.
A review of Resident 710's Medication Administration Record (MAR), dated May 2021, indicated Resident 710 did not receive Valium on 5/5/21 at 9:30 p.m.
During an interview on 5/6/21, at 1:48 p.m., the Director of Nursing (DON) stated Resident 710 was assigned to Licensed Vocational Nurse 10 (LVN 10) for the evening shift on 5/5/21. The DON stated that a narcotic medication needs to be recorded in MAR after it was given. She further stated that narcotics taken out of medication cart without being recorded could create a diversion. The DON stated she would investigate this issue with her staff.
During an interview on 5/6/21, at 2 p.m., with Resident 710, he stated that he received Diazepam last night at 9:30 p.m.
During an interview on 5/6/21, at 3:45 p.m., with LVN 10, he stated that he applied the seven rights of medication administration when giving medications to residents (right patient, right drug, right dose, right time, right route, right reason and right documentation).
A review of the facility's policy titled Administering Medications, dated December 2012, indicated that the individual administering the medication will record in the resident's medical record: the date and time the medication was administered; the dosage; the route of administration; the injection site (if applicable); any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed; and the signature and title of the person administering the drug.
Based on interview and record review, the facility failed to ensure an inventory list of personal belongings was completed for one of 35 sampled Residents (Resident 75). The facility also failed to follow the facility's policy on narcotic (controlled substance) medication administration for one of one sampled resident (Resident 710).
These deficient practices placed Resident 75's personal property at risk for theft and loss and had the potential to result in Resident 710's controlled medication diversion (a medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use).
Findings:
a. A review of the admission Record indicated Resident 75 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 75's diagnoses included fracture (broken bone) of the right femur (thighbone), chronic obstructive pulmonary disease (COPD, progressive disease that gets worse over time and makes it hard to breath), dementia (gradual loss of brain function and a decline in mental functioning) and psychosis (severe mental disorder in which you lose touch with reality).
The Minimum Data Set (MDS, a standardized assessment tool), dated 2/18/21, indicated the Resident 75 had short and long-term memory problems, was able to make herself understood, but had the ability to understand others. Resident 75 required total assistance with activities of daily living.
A review of Resident 75's Resident Inventory of Personal Effects (list of personal property), dated 5/23/19 and 11/16/19, indicated a blank form. There was no documented evidence that Resident 75's belongings were inventoried upon her admission and readmission to the facility.
During a telephone interview with Resident 75's RP on 5/7/21, at 8:30 a.m., the RP stated, there were two boxes of clothing sent to the facility. The RP also stated Resident 75 used to have jewelries on her, but do not have it anymore.
During a concurrent observation and interview with Licensed Vocational Nurse 8 (LVN 8) on 5/7/21, at 10 am, she confirmed Resident 75's Resident Inventory of Personal Effects forms, dated 5/23/19 and 11/16/19 were blank. LVN 8 added, personal items should have been listed upon Resident 75's admission and when new items were brought to the facility. LVN 8 also stated, it is the responsibility of everyone in the facility to log in the new items.
A review of the facility's policy and procedures titled, Personal Property, revised on 9/2012, indicated te resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the current physician certification for hospice (providing c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the current physician certification for hospice (providing care for the sick or terminally ill) benefit was renewed for one of 4 sampled residents (Resident 75).
This deficient practice had the potential for miscommunication regarding Resident 75's hospice care.
Findings:
A review of Resident 75's admission Record indicated the facility admitted the resident on [DATE], with diagnoses of fracture (broken bone) of the right femur (thighbone), chronic obstructive pulmonary disease (COPD- progressive disease that gets worse over time and makes it hard to breath), dementia (gradual loss of brain function and a decline in mental functioning) and psychosis (severe mental disorder in which you lose touch with reality).
A review of Resident 75's physician's order dated [DATE], indicated to admit Resident 75 under hospice care (providing supportive care to people in the final phase of a terminal illness and focus on comfort and quality of care, rather than cure).
A review of Resident 75's Physician's Certification for Hospice Benefit had expired on [DATE].
During an interview on [DATE] at 11:26 am, Licensed Vocational Nurse 6 (LVN 6) stated Resident 75's should have an updated certification in the resident's clinical records.
A review of the facility's Hospice Program policy and procedure with a revised date of [DATE], indicated the facility was responsible in obtaining the physician's certification and recertification of the terminal illness specific to each resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide a functional phone connection for the residents and visitors.
This deficient practice resulted for the residents' family members no...
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Based on interview and record review the facility failed to provide a functional phone connection for the residents and visitors.
This deficient practice resulted for the residents' family members not to be able to communicate with the residents and with facility staff.
a. During an interview on 5/7/21, at 8:53 a.m., RP 1 stated the biggest complaint about the facility was the terrible phone service. RP 1 attempted to call multiple times this past week, but the receptionist did not pick up.
A review of the map indicated the facility had six nursing stations. A review of the facility's census, dated 5/3/21, indicated the facility had 212 residents.
During an interview on 5/7/21, at 1:03 p.m., Administrator (ADM) stated the facility had only three telephone lines. Director of Nursing (DON) was aware the phone lines were problem since physicians had difficulty calling the facility. The facility contacted the phone company and installed another router. ADM and DON were aware the additional router did not resolve the telephone service problem.
b. During an interview on 5/3/21 01:47 PM with LVN 4, who states communication with Resident 91 are made with daughters or thru Google translator.
During a telephone interview on 5/4/21 at 11:50 AM with Resident 91's family member (FMML 2B), she stated was unable to speak with staff regarding resident's health status on multiple occasions last year because phone calls were not being answered or calls were being transferred to nurse stations other than Resident 91's.
c. During a telephone interview on 5/3/21 at 12:16 PM, Resident 187's family (FAM 1) stated she and other family members were not updated or informed of the Resident 187 change of condition for months. FAM 1 stated, for the past six months when she calls the facility to inquire about Resident 187's status, the phone rings repeatedly and no one would answer the phone, or if the call transferred to another area, the call dropped and the facility did not call FAM 1 back.
During an interview on 5/7/21 at 12:30 PM, the Administrator (ADM) stated, she was aware of the issues about the internet problem in the facility which caused the incoming call to drop or get disconnected. The ADM stated the lost internet connection could be the reason for the phone calls not to be answered.
During an interview on 05/07/21 at 1:03 PM, the DON stated the concern was brought to the Quality Assurance Program Improvement Commitee meeting in the last quarter but the phone lines and internet connections are still a problem.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Resident's responsible party (RP) receive information on ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Resident's responsible party (RP) receive information on resident's clinical condition, healthcare information and plan of care for one of 35 sampled Residents (Resident 187).
This failure had the potential to violate the resident's or RP's rights to be informed and to choose the type of care or treatment to be received, or alternatives the resident or responsible party preferred.
Findings:
A review of the Face Sheet (admission Record) indicated Resident 187 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).
A review of the Minimum Data Set (MDS, standardized assessment and care screening tool), dated 1/11/21, indicated Resident 187 was unable to speak and was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making.
During a telephone interview, on 5/3/21 at 12:16 PM with Resident 187 family (FAM 1), she stated she and other family members were not updated or informed of Resident 187's change of condition for months. FAM 1 stated, for the past six months when she would call the facility to inquire about Resident 187's status, the phone would ring repeatedly and no one would answer the phone. FAM 1stated if the call was answered, it would be transferred to another area and eventually the call would drop. FAM 1 stated the facility does not call.
During an observation and interview on 5/4/21, at 10:41 AM, with Licensed Vocational Nurse (LVN17), Resident 187 was observed lying in bed and was unable to speak and make needs known when spoken to. LVN17 stated she had not spoken to any family members about Resident 187's condition.
During an interview on 5/6/2, at 11:47 AM, with the Assistant Director of Nursing (ADON), she stated, it was important for the RPs to be updated with the residents' healthcare condition so they can make healthcare decision to ensure the residents' rights were implemented.
During an interview and concurrent interview on 5/7/21 at 11:30 AM, with the Social Service Designee 1 (SSD 1) and SSD 2, they stated they were not aware why the Social Service Director (SSD) did not inform or invite Resident 187's RP to the quarterly IDT (Interdisciplinary Team, involving two or more disciplines or fields of study) meeting to discuss Resident 187's change of condition or treatments from 1/2021 to present. SSD 1 stated there was no record to indicate Resident 187's RP participated in any zoom meeting.
During an interview on 5/7/21, at 12:30 PM, with the Administrator (ADM), she stated, there were issues about the internet problem in the facility, which causes the incoming calls to drop or get disconnected. ADM stated this could be the reason for the phone calls of the RPs to be lost or not answered.
During an interview on 05/07/21, at 1:03 PM with the DON, she stated the concern regarding the internet connection and phone lines were brought to the Quality Assurance Program Improvement Commitee last quarter, but they remain to be a problem.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. A review of the Face Sheet indicated Resident 649 was admitted to the facility on [DATE] with diagnosis of left side hemipleg...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. A review of the Face Sheet indicated Resident 649 was admitted to the facility on [DATE] with diagnosis of left side hemiplegia (paralysis to one side of the body) following cerebral infarction.
A review of the MDS, dated [DATE], indicated Resident 649 was able to express his ideas and wants and understands others. Resident 649 required extensive assistance with one person assist for bed mobility and total assistance with transfer, toilet use, and personal hygiene.
During a concurrent interview and observation on 5/3/21 at 9:36 am, Resident 649 stated, I don't know where that thing is. The call light was observed hanging from the wall on the floor and not within Resident 649's reach.
During a review of Resident 649's Care Plan, titled, ADL, dated 4/12/21, included intervention to have call light within reach and staff to answer promptly.
A review of the facility's policy titled, Quality of Life - Accommodation of Needs, revised in August 2009 indicated that the staff should interact with the residents in a way that accommodates the physical or sensory limitations of the residents. The policy indicated that the staff behaviors are directed toward assisting the residents in maintaining dignity and well-being.
e. A review of the Face Sheet indicated Resident 93 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of hemiplegia (paralysis of one side of the body) following cerebral infarction affecting the left non-dominant side.
A review of Resident 93's MDS, dated [DATE], indicated Resident 93's cognition was mildly impaired. Resident 93 required extensive assistance with a two-person physical assist to perform ADL such as toileting.
During an interview on 5/07/21, at 8:15 AM, Resident 93 stated, whenever he would press the call light for a diaper change, he ends up falling asleep while waiting for the CNA. Resident 93 added, on other occasions, the CNA would answer the call light and tell him that he would be back, but the CNA does not return until 30-45 minutes later.
A review of the facility's policy titled, Quality of Life - Accommodation of Needs, revised in August 2009 indicated that the staff should interact with the residents in a way that accommodates the physical or sensory limitations of the residents. The policy indicated that the staff behaviors are directed toward assisting the residents in maintaining dignity and well-being.
Based on observation, interview and record review, the facility failed to reasonably accommodate the needs of five of 35 sampled Residents (Residents 4, 27,75, 93 and 649) by:
a.b Residents 4 and 27's call light were not answered timely.
c. Resident 75's call light was not within reach. Resident 75 complained of being cold during the entire bed bath and the staff ignored her.
d. Resident 649's call light was not within reach and was found on the floor.
e. Resident 93's call light was not answered timely.
This deficient practice had the potential for the residents not to be able to call the staff for assistance, which could result to not receiving or delayed needed care or services necessary for the residents' well-being.
Cross reference F725
Findings:
a. A review of the Face Sheet (admission Record) indicated Resident 4 was admitted on [DATE] with diagnosis of cerebral infarction (brain tissue damage due to a loss of oxygen to the area).
A review of Resident 4's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 4/14/21, indicated Resident 4's cognition was intact. Resident 4 required extensive assistance with a one-person physical assist to perform activities of daily living (ADL) such as toileting and personal hygiene.
During an interview on 5/07/21, at 8:10 AM, Resident 4 stated, about three months ago, whenever he would press the call light for a diaper change, the Certified Nurse Assistant (CNA) would come to the room and tell him that he/she would be right back but the CNA does not return until 30 minutes later. Resident 4 stated this happened about three times.
A review of the facility's policy titled, Quality of Life - Accommodation of Needs, revised in 8/2009 indicated that the staff should interact with the residents in a way that accommodates the physical or sensory limitations of the residents. The policy indicated that the staff behaviors are directed toward assisting the residents in maintaining dignity and well-being.
b. A review of the Face Sheet indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's diagnoses included atrial fibrillation (irregular heart beat) and neuralgia (an intense, typically intermittent pain along the course of a nerve, especially in the head or face).
A review of the MDS, dated [DATE], indicated Resident 27 had no impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 27 required limited assistance with personal hygiene and total assistance with one person for toilet use. Resident 27 had limited range of motion on both lower extremities.
During an interview on 5/3/21 at 12:38 pm, Resident 27 stated, the facility staff does not answer the call light half of the time when she needed assistance to change her brief, wash up or toilet use. Resident 27 stated she reported the concern to the charge nurses, but it is still a problem.
During a concurrent observation and interview on 5/7/21, at 9:48 a.m., Resident 27's call light was on and there was no staff observed in the hallway. Resident 27 stated she had been waiting for more than 15 minutes for the staff to come back to bring her towels and to assist with washing her face and body.
During an interview on 5/7/21, at 11:32 a.m. the Director of Nursing (DON) stated the call lights should be answered timely to meet the resident's needs.
A review of the facility's policy and procedure, titled Accommodation of Needs-Quality of Life, dated 8/2009, indicated the resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.
c.1 A review of the Face Sheet indicated Resident 75 was admitted to the facility on [DATE]. Resident 75 diagnoses included were fracture (broken bone) of the right femur (thighbone), chronic obstructive pulmonary disease (COPD, progressive disease that gets worse over time and makes it hard to breath), dementia (gradual loss of brain function and a decline in mental functioning) and psychosis (severe mental disorder in which you lose touch with reality).
A review of the MDS, dated [DATE], indicated Resident 75 had short and long-term memory problems, was able to make herself understood and had the ability to understand others. Resident 75 required total assistance with activities of daily living.
During observation on 5/3/21, at 10:39 am, two staff were observed assisting Resident 75 with bed bath. During this observation, Resident 75 told the staff twice that she was feeling cold. On both times, the staff ignored Resident 75 and told the resident the water was warm. One of the staff covered Resident 75's upper torso with another towel leaving the lower torso exposed. No other covering was given to the resident to prevent her from feeling cold.
During an interview, after Resident 75's bed bath, on 5/3/21, at 11 am, both CNAs stated Resident 75 complained too much especially during bed bath. They both stated that they should have provided the resident a bed blanket instead of just a towel.
During an interview on 5/3/21, at 11:26 a.m., Licensed Vocational Nurse 7 (LVN 7) stated a bed blanket should have been provided for warmth and privacy.
A review of the facility's policy and procedure, titled Bed Bath, revised on 2/2018, indicated not to expose the resident and to use bed blanket during bed bath.
c.2. During an observation on 5/3/21, at 10: 45 am, Resident 75 was lying in bed with her call light not within reach. During an interview, Resident 75 stated she never had the call light with her because it was never given to her. Resident 75 added she could have used it to call for assistance especially if she needed assistance in repositioning herself.
During a concurrent observation and interview on 5/3/21, at 10:50 am, with CNA 6, she confirmed the call light was not with the Resident 75's reach. CNA 6 looked around and found the call light behind the resident's head of bed.
During an interview with LVN 7 on 5/6/21, at 3:04 pm, she stated the call light should always be reachable.
A review of the facility's policy and procedure, Answering the Call light, revised 10/2010, indicated, when the resident is in bed or confined to a chair be sure the call light is within reach.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain normal water temperatures.
This deficient practice had the potential for the residents to experience uncomfortable w...
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Based on observation, interview, and record review, the facility failed to maintain normal water temperatures.
This deficient practice had the potential for the residents to experience uncomfortable water temperatures.
Findings:
1. During an interview on 5/5/21, at 9:15 AM, Resident 40 stated the hot water temperature for bed baths (a cleansing of a person in bed) has been too cold for months.
During an observation, on 5/5/21, at 9:15 AM, in the bathroom of room A, the hot water temperature from the faucet was 96.3 degrees Fahrenheit (F - a scale of temperature measurement) using a digital thermometer.
During a concurrent observation and interview, on 5/5/21, at 9:20 AM, in the bathroom of Room A, the Maintenance Supervisor recorded a water temperature of 101 degrees F using a dial thermometer. Maintenance supervisor stated the hot water temperature should register between 105 and 120 degrees F.
During a concurrent observation and interview, on 5/5/21, at 9:23 AM, in the bathroom of Room B, the hot water temperature was 78.5 degrees F using the digital thermometer.
2. During an interview, on 5/5/21, at 1:32 PM, Resident 131 stated when Nursing staff offers shower at around 3:30 PM, she doesn't take a shower because the water is too cold. Resident 131 stated she waits until Saturday mornings because the water is warmer. Resident 131 stated it makes her feel sad and dirty when she can't take a hot shower.
During a concurrent observation and interview, on 5/7/21, at 8:56 AM, upon entering Room A, Maintenance Supervisor checked the hot water temperature from the bathroom faucet. The initial water temperature was measured at 96.4 degrees F. The water temperature was 100.0 degrees Fahrenheit after 5 minutes. This bathroom is shared between Room C and Room A. There were 2 residents in each room.
During a concurrent observation and interview, on 5/7/21, at 9:05 AM, with the Maintenance Supervisor, the hot water temperature from the bathroom faucet was measured at 125.0 degrees F.
During a concurrent observation and interview, on 5/5/21, at 11:30 AM, Maintenance supervisor showed the boiler (a closed container in which water is heated) room. Maintenance supervisor cannot show where the temperature settings are on the 2 boilers in the room. Maintenance supervisor stated he does not know what the temperature settings are or how to change the temperature settings.
A review of the facility policy and procedure titled, Safety of Water Temperature, revised on 12/2009, indicated water heaters that service resident rooms, bathrooms, common areas , and tub/shower areas shall be set to temperature of no more that 120 F, or the maximum allowable temperature per state regulation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to indicate in writing the address where three of three sampled reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to indicate in writing the address where three of three sampled residents (Residents 249, 250, and 253) were discharged to.
This deficient practice had the potential for the residents who left the facility not knowing whether their destination was safe and not be able to receive the continuity of care they needed.
Findings:
a. A review of Resident 249's admission Record indicated the facility readmitted the resident on 4/5/2021, with diagnoses of tracheostomy (surgical procedures on the neck to open a direct airway through an incision in the trachea or windpipe) and dependence on respirator (use of a machine to help in breathing).
A review of Resident 249's Physicians Discharge summary dated [DATE] indicated the resident was discharged to the hospital on 4/8/2021.
A review of Resident 249's Notice of Proposed Transfer and discharge date d 3/26/2021, indicated there was no address where the resident was discharged to.
During an interview on 5/7/2021 at 10:27 am, Social Service Designee (SSD) 1 and 2 stated that it was the responsibility of the staff whoever discharged the resident to ensure the address to where the Resident 249 was discharged to was completed.
b. A review of Resident 250's admission Record indicated the facility readmitted the resident on 12/13/2019, with diagnoses of respiratory failure, tracheostomy and dependent on respirator.
A review of Resident 250's undated Physician's Discharge summary dated [DATE] indicated Resident 250 was discharged to a hospital on 4/2/2021 due to respiratory distress.
A review of Resident 250's Notice of Proposed Transfer and discharge date d 4/2/2021, did not indicate the address where the resident was transferred to.
During an interview with SSD 1 and 2 on 5/7/2021, at 10:30 am they both stated the staff needed to write down the address where Resident 250 was discharged to.
c. A review of Resident 253's admission Record indicated the facility admitted the resident on 3/18/2021 with diagnoses of right hand fracture (broken bone), diabetes mellitus (high sugar in the blood system) and muscle weakness.
A review of Resident 253's Physician's Discharge summary dated [DATE], indicated Resident 253 was discharged home on 3/26/2021.
A review of Resident 253's Notice of Proposed Transfer and discharge date d 3/26/2021, indicated a post office box (PO Box) number, and not the address where the resident was discharged to.
During an interview on 5/7/2021 at 10:35 am, SSD 1 stated that the address should have been written down in case there was a need for a follow up care.
A review of the facility's Discharging the Resident policy and procedure with a revised date of December 2016, indicated to inform the resident where the new facility was located.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident assessment accurately reflected th...
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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 assessment accurately reflected the resident's status for one of 35 sampled Residents ( Resident 27). Resident 27 with hearing impairment was assessed and recorded as no hearing difficulties
This had the potential for the resident not to receive the appropriate and necessary care, treatment and services, which can adversely affect quality of life
Findings:
A review of the Face Sheet (admission Record) indicated Resident 27 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation ( irregular heart beat) and neuralgia (an intense, typically intermittent pain along the course of a nerve, especially in the head or face).
A review Minimum Data Set (MDS, resident assessment and care screening tool), dated 2/2/21, indicated Resident 27 had no impairment in cognitive skills for daily decision making. The MDS also indicated Resident 27 had adequate ability to hear, no hearing aide and no difficulty with normal conversation.
During an interview and concurrent observation on 5/6/21, at 9:56 AM, Resident 27 spoke loudly when answering questions and asked if the surveyor could talk to her closer to her right ear. Resident 27 stated she could not hear and she does not have a hearing device.
During an interview on 5/6/21, at 10:02 AM, Licensed Vocational Nurse 3 (LVN 3) stated Resident 27 does not have a hearing device and she usually spoke to her loudly because of her hearing difficulties.
During a record review and concurrent interview on 5/07/21 at 8:05 AM, the MDS Nurse stated, Resident 27 had a hearing impairment and should had been assessed as having hearing difficulty in the MDS to ensure the resident received the assistance needed for hearing.
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** h. A review of Resident 146's Face Sheet (an admission record), indicated the facility admitted the resident on 3/23/21 with dia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** h. A review of Resident 146's Face Sheet (an admission record), indicated the facility admitted the resident on 3/23/21 with diagnoses of chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen) and dependence on ventilator (a machine that provides mechanical ventilation by moving breathable air into and out of the lungs).
A review of Resident 146's Psychotropic Assessment, dated 3/24/21, indicated the resident has diagnoses of mental illness as psychosis (A mental disorder characterized by a disconnection from reality).
A review of Resident 146's History and Physical Examination, dated 3/24/21, indicated the resident was admitted with tracheostomy tube (a tube inserted in the neck below the vocal cords for breathing) and percutaneous endoscopic gastrostomy tube (PEG, a flexible feeding tube placed into the stomach).
A review of Resident 146's MDS, dated [DATE], indicated resident had severe impairment for decision making and required extensive assistance for activities in daily living (ADL, such as dressing, toilet use and personal hygiene) as well as one-person assist for bed mobility, and two-person assist for transfer.
A review of Resident 146's medical record, titled Patient Care Plan: Psychotropic Medication, dated 3/23/21, the plan of care did not include Ativan and did not include non-pharmacological approached intervention to address the behavior of tube pulling.
A review of Resident 146's Physician Orders, dated May 2021, indicated an order for the resident to receive Ativan 0.5 mg every six hours as needed for anxiety as manifested by pulling of medical equipment or tubing for a period of 14 days.
During an observation on 5/3/21, at 10:45 p.m., Resident 146 was lying in bed with eyes closed and with calm and even breathing.
i. A review of Resident 163's Face Sheet, undated, indicated the facility admitted the resident on 3/31/21 with diagnoses of Candida sepsis (a body's extreme response to a fungal infection), urinary tract infection (an infection in urinary system), pneumonia (an infection in one or both lungs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 163's Physician Orders, dated May 2021, indicated an order for the resident to receive Ritalin 5 mg twice a day, starting on 3/31/21.
A review of Resident 163's MDS, dated [DATE], indicated the resident had severe impairment for decision making and was totally dependent on staff for activities of daily living as well as requiring one-person assist for bed mobility and transfer.
During an observation on 5/3/21, at 11:48 a.m., Resident 163 was sleeping with no distress.
During an interview on 5/7/21 at 8:42 a.m., Registered Nurse 4 (RN 4) stated an individualized care plan was not initiated for the use of Ritalin. RN 4 also stated that a care plan must be done for psychotropic medications according to the facility's policy.
A review of Resident 163's Multi-IDT (interdisciplinary team) Conference, undated, indicated that the resident's medication regimen was not discussed.
A review of the facility's policy and procedure titled Care Planning - Interdisciplinary Team, dated December 2016, indicated a comprehensive, person-centered care plan that include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
A review of a publication on www.ncbi.nlm.nih.gov/books/NBK482451/?report=printable, indicated off-label use of Ritalin for treatment of depression in the elderly population.
g. A review of Resident 91's Face Sheet indicated the facility admitted Resident 91 on 3/25/2014 and readmitted the resident on 11/8/2019 with diagnosis of dementia (gradual decrease in memory and cognition [ability to think and reason that affect a person's daily functioning).
A review of Resident 91's MDS dated [DATE], indicated Resident 91 had minimal difficulty with hearing, and had clear speech and capable of expressing ideas and wants.
A review of Resident 91's Physicians Order dated 5/2021, indicated Resident 91 could have an audiology consult (a specialized in assessment of hearing) and follow up as needed (PRN).
During an interview and observation on 5/3/2021 at 1:25 pm, Resident 91 pointed to her ear and stated she was hard of hearing. Resident 91's speech volume high when speaking. Resident 91 informed the surveyor to speak louder and closer. Resident 91 stated she did not own a hearing device.
During Interview on 5/3/2021 at 1:47 pm, LVN 4 stated Resident 91 did not have hearing aids.
During interview on 5/4/2021 at 11:41 am, FAM 2A stated Resident 91 had history of having a lot of earwax which was removed at a hospital. FML 2A stated extensive amount of earwax was removed from each ear.
During a record review and concurrent interview on 5/7/2021 at 12:22 pm the MDS Nurse 3, stated Resident 91 was assessed with minimal difficulty with hearing and a care plan was not developed to address the interventions for hearing difficulties. MDS Nurse 3 stated Resident 91 should have been referred to social services for audiology or ENT (Ear, Nose and Throat specialist) for evaluation.
f. A review of Resident 133's Face Sheet indicated the facility admitted the resident on 3/19/2021 with diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities).
During a review of Resident 133's Anxiety care plan dated 3/31/2021 indicated restlessness, as a behavior of anxiety and the interventions were to encourage activities of choice.
During an observation and interview on 5/7/2021 at 10 am Resident 133 was calm sitting in a wheelchair calm and stated she slept well.
During an interview on 5/7/2021 at 11:51am, LVN 6 stated Resident 133's Patient Care Plan for Anxiety did not describe the resident's behaviors of restlessness (feeling the need to constantly move). LVN 6 could not describe or give an example of how resident 133 exhibited restlessness.
e. A review of Resident 75's Face Sheet indicated Resident 75 was re-admitted to the facility on [DATE] from the GACH. Resident 75's diagnoses included but was not limited to right intertrochanteric femur (located in the thigh bone close to the hip) fracture, unspecified dementia without behavioral disturbance, history of falling, and sacral (tail bone) stage 4 pressure ulcer (bed sore with full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone).
A review of the minimum data set (MDS, a comprehensive care planning tool), dated 2/25/20, indicated Resident 75 was moderately impaired for daily decision making. The MDS indicated Resident 75 did not have any functional ROM limitations in both legs.
A review of Resident 75's MDS, dated [DATE], 8/20/20, 11/20/20, and 2/18/21, indicated both legs had functional ROM limitations.
A review of the Rehabilitation Functional ROM (range of motion) and Voluntary Movement Screen, dated 2/15/20, indicated Resident 75 had no ROM limitations in both legs.
During an observation on 5/3/21, at 12:40 pm, in Resident 75's room, Resident 75 was lying in bed. Resident 75's right leg crossed midline over the left leg and dangled over the left side of the bed. Resident 75's left leg was crossed underneath the right leg with the left hip positioned in external rotation (hip rotated away from the body) and knee bent. Resident 75's left leg position resembled sitting on the floor with legs crossed in front of the body. Resident 75 complained of left leg pain.
During an interview on 5/4/21, at 2:49 p., Certified Nursing Assistant 6 (CNA 6) stated the Resident 75's legs were always crossed.
During an interview on 5/7/21, at 1:31 pm, MDS Coordinator (MDS 1) stated that all current care plans should be in the clinical record. MDS 1 reviewed Resident 75's MDS assessments dated 2/25/20 and 5/21/20. MDS 1 stated Resident 75 had a significant decline in range of motion to both legs on the 5/21/20 MDS assessment. MDS 1 stated Resident 75's clinical record did not have any care plans to address the decline in range of motion to both legs. MDS 1 stated that the care plan should have been completed since Resident 75 was under the facility's care.
A review of the facility's policy entitled, Care Plans - Comprehensive revised September 2010, indicated that Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes.
Based on observation, interview and record review the facility failed to develop and implement a comprehensive, resident specific plan of care for nine of 35 sampled Residents (Residents 27, 48, 167, 75, 133, 91, 146 and 163)
a. Resident 27 did not have a care plan to address hearing difficulties.
This deficient practice had resulted in the resident's difficulty in miscommunication and a potential not to receive neccessary care and services.
b. Resident 48's care plan was not implemented to monitor the resident for bleeding and bruising while receiving Xarelto ( a medication to prevent development of blood clot or blood thinner).
c. Resident 167's care plan was not implemented to monitor the resident for bleeding and bruising while receiving Coumadin (a medication to prevent development of blood clot or blood thinner).
These deficient practices had the potential for the residents to experience bleeding or bruising and result in lack of immediate care or complications related to bleeding.
d. Resident 75 did not have a care plan to address skin rashes. This had the potential for the resident not to receive appropriate care and treatment and inadequate monitoring of the resident's progress and changes in condition.
Resident 75 did not have a care plan to address decline in range of motion (ROM) for both legs. This resulted in Resident 75 not receiving intervention with ROM exercises to prevent contractures (chronic loss of joint motion to both legs.
Cross reference F688
f. Resident 133 did not have a care plan to address resident's behavior when feeling anxiety ( (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities)
g. Resident 91's care plan intervention to have an audio consult was not implemented to address possible hearing impairment.
h. Resident 146 did not have an individualized care plan to address the use of Ativan (anitanxiety) and the behavior of pulling out tubing.
i. Resident 163 did not have an individualized care plan to address the use of Ritalin (a medication for attention deficit hyperactivity disorder).
These failures had the potential for residents not to receive interventions to address specific needs, which could affect quality of life.
Findings:
a. A review of the Face Sheet (admission Record) indicated Resident 27 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation ( irregular heart beat) and neuralgia (an intense, typically intermittent pain along the course of a nerve, especially in the head or face).
A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 2/2/21, indicated Resident 27 had no impairment in cognitive skills for daily decision making. According to the MDS, Resident 27 had adequate ability to hear, no hearing aide and no difficulty with the normal conversation.
During an interview on 5/6/21, at 9:56 AM, Resident 27 was observed with the loud voice when answering questions. Resident 27 asked if the surveyor could talk to her closer to her right ear because she could not hear and she does not have a hearing device.
During an interview on 5/6/21, at 10:02 AM, Licensed Vocational Nurse 3 (LVN 3) stated Resident 27 does not have a hearing device and she usually spoke to her loudly because of her hearing difficulties.
During an interview and concurrent record review on 5/7/21, at 8:05 AM , MDS Nurse 1 stated Resident 27 was hard of hearing. MDS Nurse 1 stated there was no care plan developed to indicate the interventions needed to assist the resident with the hearing difficulty and the need for hearing device.
During an interview with the Certified Nursing Assistant 5 (CNA 5) on 5/7/21, 8:45 AM, she observed Resident 27 with a hearing difficulty for at least three years and she had not seen the resident use a hearing device.
b. A review of the Face Sheet indicated Resident 48 was readmitted to the facility on [DATE] with diagnosis of atrial fibrillation (a heart condition that results in irregular heart rate which is a risk for developing blood clot).
A review of the MDS, dated [DATE], indicated Resident 48 was able to understand others and make herself understood. Resident 48 was moderately impaired in memory and cognition (ability to think and reason).
During an observation on 5/3/21, at 8:49 AM, Resident 48 was observed sleepy and unable to answer questions when interviewed.
During a concurrent record review of the physician order and the Medication Administration Record (MAR) and interview with LVN 3 on 5/6/21, at 10:43 AM, she stated Resident 48 was receiving anticoagulant medication Xarelto (a medication that for blood thinner) 20 milligrams (mg) tablet one tablet by mouth at bedtime and to be given with food.
A review of Resident 48's care plan titled, Anti-coagulant, dated 2/8/2, indicated Resident 48 need anticoagulant medication for atrial fibrillation and was at risk for adverse side effect (ASE) of bleeding. The plan of care indicated to minimize ASE from medication manifested by bleeding, bruising,vomiting of blood, petechiae ( are pinpoint, round spots that appear on the skin as a result of bleeding) and melena (blood in the stool), Resident 48 will be monitored for ASE.
The care plan interventions included for Resident 48 to be monitored for ASE of the medication such as bleeding, bruising,vomiting of blood, petechiae ( are pinpoint, round spots that appear on the skin as a result of bleeding) and melena (blood in the stool).
During a concurrent record review and interview on 5/6/21 at 10:45 AM, LVN 3 stated the plan of care was not implemented. LVN 3 stated there was no record in the MAR, Treatment Record of the Nursing Progress Notes that Resident 48 was monitored for bleeding, bruising and other side effects of Xarelto.
c. A review of the Face Sheet indicated Resident 167 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included left side hemiphlegia (paralysis to one side of the body ) following cerebral infarction ( a brain damage due to lack of clood flow and oxygen to the brain).
A review of the MDS, dated [DATE], indicated Resident 48 was able to understand others and make herself understood. Resident 48 was moderately impaired in memory and cognition ( ability to think and reason).
During an observation on 5/6/21, at 8:49 AM, Resident 48 was observed in the hallway, sitting in the wheelchair, with slurred speech when interviewed.
During a concurrent record review of the physician order and the MAR and interview with LVN 3 on 5/6/21 at 11:56 AM, LVN 3 stated Resident 48 was receiving anticoagulant medication Coumadin (blood thinner medication) five milligrams (mg) one tablet by mouth at 5 PM for cerebrovascular accident (CVA, death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired) prophylaxis (prevention).
A review of the plan of care titled, Anti-coagulant, dated 8/19/21 indicated Resident 167 need anticoagulant medication for deep vein thrombosis (DVT, a blood clot in the vein) and was at risk for adverse side effect (ASE) of bleeding. The plan of care indicated to minimize ASE from medication manifested by bleeding, bruising,vomiting of blood, petechiae ( are pinpoint, round spots that appear on the skin as a result of bleeding) and melena (blood in the stool), Resident 167 will be monitored for ASE.
During a concurrent record review and interview with LVN 3 on 5/6/21, at 11:56 AM, she stated the plan of care was not implemented. LVN 3 stated there was no record in the MAR, Treatment Record of the Nursing Progress Notes that Resident 167 was monitored for bleeding, bruising, and other side effects of Coumadin. LVN 3 stated monitoring the side effects of Coumadin was important because it will prevent complications related to bleeding.
d. A review of the admission Record indicated Resident 75 was admitted to the facility on [DATE]. Resident 75's diagnoses included fracture (broken bone) of the right femur (thighbone), chronic obstructive pulmonary disease (COPD, progressive disease that gets worse over time and makes it hard to breath), dementia (gradual loss of brain function and a decline in mental functioning) and psychosis (severe mental disorder in which you lose touch with reality).
A review of the MDS, dated [DATE], indicated the patient had short and long-term memory problem, was able to make herself understood, and had the ability to understand others. Resident 75 required total assistance with activities of daily living.
During the initial tour on 5/3/21, at 9 AM, Resident 75 was observed lying in bed. Resident 75 was observed scratching her upper body, both arms and neck. On closer observation, Resident 75 was observed with multiple raised bumps on her back, front body, both arms, neck and shoulder. Resident 75 stated she just wants the itching to stop.
During a concurrent record review and interview with LVN 7 on 5/3/21, at 9:30 a.m., she stated Resident 7 has been receiving cream for the skin rashes. LVN 7 stated there was no care plan developed for Resident 75's skin rashes.
A review of the physician's order dated 4/13/21, indicated Naftifine Hydrochloride (antifungal) 2 % cream to apply to affected areas, bilateral thighs and bilateral arms two times a day (BID) for 4 weeks for contact dermatitis. The physician also had ordered Flucinonide 0.1 5 cream , apply to affected areas, bilateral thighs and bilateral arms BID for 4 weeks.
A review of the facility's policy and procedure, titled Care Plans-Comprehensive dated 9/2010, indicated, The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record interview, the facility failed to provide assistance with communication for one of one sampled resident (Resident 187).
This deficient practice had the pote...
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Based on observation, interview, and record interview, the facility failed to provide assistance with communication for one of one sampled resident (Resident 187).
This deficient practice had the potential for Resident 187 not to communicate effectively.
Findings:
A review of Resident 187's Face Sheet (admission record) indicated the facility admitted Resident 187 on 1/31/2012 and readmitted the resident on 11/17/2019 with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).
A review of Resident 187's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 1/11/2021, indicated Resident 187 was unable to speak, and was severely impaired in cognitive skills for daily decision making.
During an observation on 5/4/2021 at 10:41 am, Resident 187 was awake nonverbal and made an incomprehensible sound.
During an interview and concurrent observation on 5/4/2021 at 11:10 am Licensed Vocational Nurse 17 (LVN 17) stated there was no communication board or device. LVN 17 stated Resident 187 could benefit from a communication board with a picture.
During an interview on 5/4/2021 at 11:25 am, Certified Nursing Assistant Nurse 5 (CNA 5) stated Resident 187 was nonverbal and spoke a foreign language which she could not speak. CNA 5 stated it would help if Resident 187 had a communication tool at the bedside.
A review of the facility's Quality of Life-Accommodation of Needs policy and procedure with a revised date of August 2009, indicated the resident's individual needs and preferences should be accommodated to the extent possible.
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
Based on observation, interview, and record review, the facility failed to evaluate Resident 75's treatment for skin rash.
This deficient practice had the potential for Resident 75 not to receive the ...
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Based on observation, interview, and record review, the facility failed to evaluate Resident 75's treatment for skin rash.
This deficient practice had the potential for Resident 75 not to receive the appropriate care and treatment and inadequate monitoring of the resident's progress and changes in condition.
Findings:
A review of Resident 75's Face Sheet (admission Record) indicated the facility admitted Resident 75 on 4/19/2019 and readmitted the resident on 11/15/2019 from a general acute care hospital (GACH) with diagnoses of right intertrochanteric femur fracture (broken hip), dementia (loss of memory and other mental abilities severe enough to interfere with daily life), and history of falling
A review of Resident 75's Minimum Data Set (MDS, a comprehensive care planning tool), dated 2/18/2021, indicated Resident 75 was totally dependent for eating and required one person to assist.
During an observation on 5/3/2021 at 9 am, Resident 75 was lying in bed and was scratching her upper body, both arms and neck. On closer observation, resident was observed with multiple raised bumps on her back and font body, both arms, neck and shoulder.
A review of Resident 75's physicians order dated 4/13/2021, indicated for the resident to receive Naftifine HCL 2 % cream (medication to treat skin conditions) to apply to affected areas, bilateral (both) thighs and bilateral arms two times a day (BID) for 4 weeks for contact dermatitis (a condition that makes skin red or inflamed). The physician orders indicated for the resident to receive Flucinonide 0.1 % cream (medication used to treat a variety of skin conditions), apply to affected areas, bilateral thighs and bilateral arms twice a day for 4 weeks.
During an interview and a review of Resident 75's medical record on 5/3/2021, at 9:30 am, Licensed Vocational Nurse 7 (LVN 7) stated Resident 7 had been receiving the cream for the skin rashes since 4/13/2021 and stated there was no documented evidence that there was an evaluation if the treatment was effective.
A review of the facility's Care Plans-Comprehensive facility's policy and procedure, dated 9/2010, indicated, the care planning interdisciplinary team was responsible for the review and updating the resident's plan of care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 91's Face Sheet, indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 91's Face Sheet, indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (gradual decrease in memory and cognition [ability to think and reason that affect a person's daily functioning) without behavioral disturbances and major depressive disorder (persistent feeling of sadness and loss of interest).
A review of the MDS, dated [DATE], indicated Resident 91 has minimal difficulty with hearing, has clear speech, capable of expressing ideas and wants and understand others.
During an observation on 5/3/21 at 1:25 PM, Resident 91 had hard of hearing and spoke loudly. A concurrent interview was conducted; Resident 91 stated, Speak up, I cannot hear!. Resident 91, stated she does not own a hearing aid device.
During an interview on 05/03/21 at 1:47 PM, LVN 4 stated Resident 91 had no hearing aid device in her personal property and she had to speak loudly to communicate with Resident 91.
A review of Resident 91's Physicians Order, dated 11/08/2019 and recapitulated (summarized) order for the month of 5/2021, indicated Resident 91 may have audiology consult (a specialized in assessment of hearing) and follow up PRN (as needed).
During a review of Resident 91's clinical record indicated, Resident 91 had no plan of care to address the resident's hearing difficult.
During a concurrent interview and record review on 5/4/21 at 11:41 AM, MDS Nurse 3 stated Resident 91 should have been referred to Social Services for Audiology (study for hearing)/or ENT (Ear, Nose and/or Throat) evaluation as MDS indicated Resident 91 had minimal difficulty with hearing on 2/26/21.
Based on observation, interview and record review, the facility failed to assist three of three sampled residents (Residents 27, 91 and 187) with proper treatment and assistive device to improve hearing abilities. The residents were not referred to the physician to assess the cause of and treatment for hearing impairment.
This deficient practice had resulted in Residents 27, 91 and 187 not able to hear staff effectively during care and had the potential to result in miscommunication about their healthcare plans that could result in decline in the quality of care and life.
Findings:
a. A review of Resident 27's Face Sheet (admission record), indicated the resident was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heart beat) and neuralgia (an intense, typically intermittent pain along the course of a nerve, especially in the head or face).
A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 2/2/21, indicated Resident 27 had no impairment in cognitive skills for daily decision making and required total assistance with one person on toilet use and limited assistance with personal hygiene. The MDS indicated Resident 27 had limited range of motion on both lower extremities.
During an observation and interview on 05/6/21 at 9:56 AM, Resident 27 was spoke loudly when answering questions. Resident 27 asked if the surveyor could speak closer to her right ear because she could not hear and she does not have hearing aid devices.
During an interview on 05/6/21 at 10:02 AM, Resident 27 stated she does not have a hearing aid device and she usually spoke loud due to her hearing difficulties.
During an interview and concurrent record review on 05/07/21 8:05 AM. MDS Nurse 4 stated Resident 27 had hard of hearing. MDS Nurse 4 stated there were no interventions to assist the resident with the hearing difficulty or obtaining hearing aid devices.
During an interview on 05/07/21 8:45 AM, Certified Nursing Assistant 5 (CNA 5) stated she observed Resident 27 with a hearing difficulty for at least three years and she had not seen the resident use hearing aid devices.
During an interview on 5/7/21 at 9:55 a.m. MDS Nurse 1 stated she spoke to Resident 27's responsible party who informed her that the resident had chronic problem with earwax and was seen by the ENT (a medical specialty in Ears, Nose and Throat) physician in the past.
During an interview and concurrent record review, the Social Service Designee 2 (SSD 2) stated there was no documented evidence Resident 27 was referred to the ENT for ear check up. SSD 2 stated Resident 27's hearing issue was not discussed during the care planning meeting to help the resident obtain hearing aid devices.
b. A review of Resident 187's Face Sheet, indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).
A review of the MDS, dated [DATE], indicated Resident 187 unable to speak, rarely make self understood, sometimes understood others and severely impaired in cognitive skills for daily decision making.
During an observation on 5/4/21 at 10:41 AM, Resident 187 was awake, non verbal and positioned with both hands closed to his chest and guarding. A concurrent interview was conducted; Resident 187 started to make a weak incomprehensible sound.
During an interview and concurrent observation on 5/4/21 at 11:10 AM, Licensed Vocational Nurse 17 (LVN 17) stated Resident 187 had hard of hearing and does not have a hearing device. LVN 17 stated she often talks to the resident loudly.
A review of Resident 187's clinical records including the nursing notes, physician record and consults notes indicated, Resident 187 had not been assessed or treated for the resident's hearing issue.
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** 2. A review of Resident 146's Face Sheet (an admission record), indicated the facility admitted the resident on 3/23/2021 with d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 146's Face Sheet (an admission record), indicated the facility admitted the resident on 3/23/2021 with diagnosis of chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen) and dependence on ventilator (a machine that provides mechanical ventilation by moving breathable air into and out of the lungs).
A review of Resident 146's Resident Care Plan for alteration in skin integrity, dated 3/23/2021, indicated resident had an unstageable pressure injury, sacrococcyx (tailbone) pressure injury, and the plan of care was to turn and reposition at least every two hours and as needed.
A review of Resident 146's MDS dated [DATE], indicated the resident had severe impairment for decision making and required extensive assistance for activities in daily living (ADL, such as dressing, toilet use and personal hygiene) as well as one-person assist for bed mobility, and two-person assist for transfer.
A review of Resident 146 Wound Assessment Report dated 4/26/2021, indicated the resident had a sacrococcyx wound debridement (medical removal of dead, damaged, or infected tissue to improve the healing) done by a wound consultant. The report also described the wound as an improved stage 4 pressure injury.
A review of Resident ADL Flow Sheet (AFS), dated May 2021, did not indicate the frequency and time of repositioning.
During an observation on 5/3/2021 at 10:48 am, Resident 146 was in a supine (lying face up) position with bent knees.
During an observation on 5/3/21 at 1:05 pm, Resident 146 was in a supine position with eyes closed.
During an observation on 5/3/21, at 2:26 pm, Resident 146 was in a supine position with bent knees and head of bed elevated to 45 degrees.
During an observation on 5/5/21, at 8 am, Resident 146 was in a supine position with a pillow under both lower legs.
During an interview on 5/5/21, at 3:31 pm, CNA 8 stated he documented repositioning in Resident 146's AFS but stated there was no place on it to chart a specific time of each repositioning.
3. A review of Resident 163's Face Sheet indicated the facility admitted the resident on 3/31/2021 with diagnosis of pneumonia (an infection in one or both lungs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 163's Resident Care Plan for alteration in skin integrity, dated 4/1/2021, indicated assist the resident on turning or repositioning every two hours and as needed for comfort.
A review of Resident 163's MDS dated [DATE], indicated the resident had severe impairment for decision making and was totally dependent on staff for activities of daily living (ADL, such as dressing, toilet use and personal hygiene), and required one-person assist for bed mobility and transfer.
A review of Resident 163's Wound Assessment Report dated 4/26/21, indicated the resident had an improved stage 3 sacrococcyx pressure injury.
A review of Resident 163's ADL Flow Sheet (AFS), dated May 2021, indicated no record of frequency or time of repositioning.
During an observation on 5/3/2021 at 11:48 am, Resident 163 was resting with eyes closed in supine position.
During an observation on 5/3/2021 at 2:35 pm, Resident 163 remained in supine position.
During an observation on 5/3/2021 at 3:41 p.m., Resident 163 was in supine position.
During an interview on 5/4/2021 at 1:30 pm, Registered Nurse 1 (RN 1),stated no one oversaw the monitoring of Resident 146 and 163 repositioning frequency.
During an interview on 5/5/2021 at 3:32 pm, CNA 9 stated she was not sure about the time when Resident 163 was last repositioned.
A review of the facility's policy and procedure titled, Repositioning, dated May 2013, indicated repositioning was critical for a resident who was immobile or dependent upon staff for repositioning. The policy indicated positioning the resident on an existing pressure ulcer should be avoided since it put additional pressure on tissue that was already compromised and may impede healing. The policy also indicated residents who were in bed should be on at least every two-hour repositioning schedule.
4. During a review of Resident 650's care plan dated 4/13/2021 indicated Resident 650 had an unstageable pressure ulcer on the sacral coccyx (tail bone) and the plan of care was to turn and reposition resident at least every two hours and as needed.
During an interview on 5/3/2021 at 2:58 pm, Resident 650 stated she had to ask the staff to reposition her.
5. During a record review of Resident 653's care plan dated 4/29/2021 indicated Resident 653 was at risk for skin breakdown and the plan of care was to reposition the resident at least every two hours.
During an interview and concurrent observation on 5/4/2021, at 10:20 am Resident 653 was lying supine in bed and stated no one would assist in turning.
During an observation on 5/4/2021 at 10:44 am Resident 653 was lying supine.
During an observation on 5/4/2021 at 12:29 pm, Resident 653 was lying supine.
During an observation on 5/4/2021 at 1:05 pm, Resident 653 was lying supine.
During an interview on 5/6/2021 at 9:09 am with Resident 653 stated the staff would not assist her in turning every two hours or sooner.
6. During a review of Resident 103's Quadriplegia care plan dated 4/21/2021 indicated Resident 103 was at risk for skin breakdown and the plan was to reposition every two hours.
During a review of Resident 103's MDS dated [DATE], indicated the resident was total dependent on staff for bed mobility.
During a review of Resident 103's Activates of Daily Living (ADL) dated for the month of May 2021 did not indicate the time and position the resident was turned.
During an observation on 5/4/2021 at 9:55am Resident 103 was supine in bed.
During an interview on 5/4/2021 at 12:58 pm, Registered Nurse 2 (RN 2) stated the staff were supposed to reposition the residents.
A review of the facility's policy and procedure titled Repositioning, dated May 2013, indicated residents who were in bed should be on at least an every two hour repositioning schedule. Documentation should be recorded in the resident's medical chart and include:
1. The position in which the resident was placed
2. The name and title of individual who gave the care
3. Any change in resident's condition
4. If the resident refused the care and why
5. Observations of anything unusual exhibited by resident
6. The signature and title of person recording data.
7. A review of Resident 136's Face Sheet indicated the facility admitted Resident 136 on 10/02/2007 with diagnoses of stage 3 pressure injury and impairment of self-care.
A review of Resident 136's MDS dated [DATE], indicated Resident 136 was totally dependent on staff for all activities of daily living such as bed mobility, transfer, locomotion, dressing, eating, toileting, personal hygiene, and bathing. MDS indicated Resident 136 was assessed as at risk for developing pressure sore. MDS indicated that Resident 136's skin and ulcer treatment included the use of pressure reducing device for bed.
A review of Resident 136's care plan, titled Skin, dated 3/15/21, indicated Resident 136 was at risk for skin breakdown and the approach was to reposition the resident every two hours and to provide pressure reducing mattress.
A review of Resident 136's physician order dated 5/2021, indicated for the resident to have a LAL mattress for wound management to be set according to resident's weight.
During concurrent observation and interview on 5/4/2021 at 4:20 pm, LVN 14 stated Resident 136 was lying supine in bed.
During observation on 5/6/2021 at 10 am Resident 136 was in a supine position.
During observation on 5/6/2021 at 12 pm Resident 136 was in a supine position.
During concurrent interview and record review on 5/6/2021 at 12:30 pm, LVN 14 stated Resident 136 needed to be repositioned.
During an observation and interview on 5/6/2021 at 3:09 pm, LVN 14 stated Resident 136 was in supine position and stated Resident 136 should be repositioned every two hours and stated the resident should be lying on the right side.
During an observation, interview, and a review of Resident 136's medical record on 5/7/2021 at 1:55 pm LVN 15 and LVN 16 stated Resident 136 was 207 pounds. LVN 15 and LVN 16 stated Resident 136's LAL mattress settings was set as 250lbs and both stated the settings were not based on the resident's current weight.
Based on observation, interview and record review the facility failed to provide care and services for 7 of 11 sampled residents (Residents 75, 136, 146, 163, 650, 653, and 103) with or at high risk for developing pressure injuries (area of damaged skin caused by staying in one position for too long) as indicated in the physician's order, plan of care and policy and procedures by failing to:.
1. For Resident 75, the staff did not apply a heal protector (devices that reduces pressure on bony areas) and did not reposition the resident at least every two hours.
2. For Resident 146 who had a stage 4 pressure ulcer (injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin), was not repositioned every two hours.
3. For Resident 163, who had a pressure injury Stage 3 (full thickness tissue loss, subcutaneous [under the skin] fat may be visible but bone, tendon or muscle are not exposed), was not repositioned every two hours.
4. For Resident 650 who was at risk for developing pressure injuries was not repositioned every two hours.
5. Resident 653 who was at risk for developing pressure injuries was not repositioned every two hours.
6. Resident 103 who had a sacral coccyx (tail bone) unstageable pressure (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [a mass of dead tissue separating from an ulcer] or eschar [dead tissue]).injury was not repositioned every two hours.
7. For Resident 136 who had a Stage 3 pressure injury, was not repositioned every two hours and the low air loss mattress (LAL mattress which operates using a blower based pump that was designed to circulate a constant flow of air), was not set according to the resident's weight to best relieve pressure. [NAME]
These deficient practices had the potential to result in the development of new and or worsened pressure injuries.
Findings:
1. A review of Resident 75's Face Sheet (admission Record) indicated the facility admitted Resident 75 on 4/19/2019 and readmitted the resident on 11/15/2019 from a general acute care hospital (GACH) with diagnoses of right intertrochanteric femur fracture (broken hip), dementia (loss of memory and other mental abilities severe enough to interfere with daily life), and history of falling.
A review of Resident 75's Minimum Data Set (MDS, a comprehensive care planning tool), dated 2/18/2021, indicated Resident 75 was non-ambulatory, incontinent of bowel and bladder, and required total assistance with all activities of daily living.
A review of Resident 75's physician's order dated 4/25/2021, indicated Resident 75 had sacrococcyx (tail bone) pressure injury (unidentified Stage) and to provide the resident with heel protectors.
A review of Resident 75's Risk for Skin Breakdown care plan dated 2/18/2021, indicated the resident was at risk for further skin breakdown and the plan was to reposition the resident at least every two hours.
During an observation on 5/3/2021 at 9 am, Resident 75 was observed lying on her back on a low air loss mattress (LAL-a mattress that provides a flow of air to assist in managing the heat and humidity of the skin).
During observations on 5/3/2021, at 12:59 pm, and at 2:30 pm, Resident 75 was observed lying on her back in bed with both feet resting directly on the bed.
During observation on 5/4/2021, Resident 75 was observed lying on her back while in bed at 7:14 am, 9:09 am, 9:50 am, 10:02 am, and 1:40 pm without heel protectors on her feet.
During an interview on 5/4/2021, at 2:50 pm, Certified Nursing Assistant 6 (CNA) 6 stated Resident 75 had wounds to her back. CNA 6 stated Resident 75 always would be on her back.
During an interview on 5/4/2021, at 3 pm, CNA 6 and Licensed Vocational Nurse 7 (LVN 7), CNA 6 stated that she was not aware Resident 75 needed to wear heel protectors and that she had been using the pillows. LVN 7 stated there should have been heel protectors applied to help prevent the development of new pressure sores. LVN 7 stated the resident should have been turned and monitor her positioning every two hours.
A review of the facility's Pressure Ulcer Risk Assessment, policy and procedure with a revised date of 9/13, indicated, The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of head around the ears, elbows, shoulder blades, backbones, hips, knees, heels, ankles and toes.
A review of the facility's Repositioning, policy and procedure, with a revised date of 5/13, indicated to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 174's Face Sheet, indicated the resident admitted to the facility on [DATE] with diagnoses that included...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 174's Face Sheet, indicated the resident admitted to the facility on [DATE] with diagnoses that included left side hemiphlegia following cerebral infarction.
A review of the MDS, dated [DATE], indicated Resident 174 had moderate impairment in memory and cognition (ability to think and reason) and required extensive assistance with one person on eating.
During a concurrent observation and interview, on 5/5/21, at 1:18 PM, Resident 174 was in bed with a food tray in front of her. LVN 6 was providing supervision during the resident's meal and assisting the resident with eating. The dietary tag on the tray indicated no straw, and there was a straw in the milk carton. LVN 6 removed the straw when the surveyor asked LVN 6 if the resident was permitted to use a straw. LVN 6 stated the resident can not have a straw because she is on aspiration precautions (an action taken in advance to prevent something dangerous from happening). LVN 6 stated the resident had a stroke (the sudden death of brain cells due to a lack of oxygen, caused by blockage of blood flow or rupture of an artery to the brain) and might aspirate when using a straw.
During a second observation and interview, on 5/5/21, at 3:53 PM, A Health shake was on Resident 174's tray at the resident's bedside. The straw was in the shake carton. LVN 8 stated to Resident 174 she needed to take the straw away because resident 174 might aspirate.
A review of Resident 174's Physician Order dated 4/28/21, indicated No straw.
Based on observation, interview and record review, the facility failed to monitor, supervise and provide assistive device to prevent accidents and injuries for two of two sampled residents (Residents 649 and 174) by failing to:
a. For Resident 649, the resident had recent history of fall and the pad alarm (a pad place on the bed that alarms when the person move off the bed) was found on the floor.
b. For Resident 174, the resident had a physician's order to not give resident a straw due to the risk of aspiration (inhalation of food or fluids into the lungs) and the resident was observed to have a straw in her drink.
These deficient practices had the potential to result in the aspiration for Resident 649 and fall with injury for Resident 174 that could lead to decline in the resident's well being of both residents.
Findings:
a. A review of Resident 649's Face Sheet (admission record), indicated the resident admitted to the facility on [DATE] with diagnoses that included left side hemiphlegia (paralysis to one side of the body) following cerebral infarction (also known as stroke or a brain damage due to lack of blood flow and oxygen to the brain).
A review of the Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/19/21, indicated Resident 649 was able to express his ideas and wants and understands others. The MDS indicated Resident 649 required extensive assistance with one person assist on bed mobility and total assistance with transfer, toilet use and personal hygiene.
A review of the plan of care, dated 4/12/21, indicated Resident 649 was at risk for fall related to Cerebrovascular attack (CVA, also known as stroke) and recent fall. The goal was to reduce the risk of fall for 90 days and the intervention was to provide assistive device and provide 1:1 sister.
During an observation on 5/04/21 at 10:21 AM, Resident 649 was observed in the room undressed with sheets and clothing on floor. Resident 649 was sitting on the side of his bed with the bed alarm on the floor on the right side of his bed.
During an interview on 5/04/21 at 10:41 AM, Licensed Vocational Nurse 9 (LVN 9) stated Resident 649 was at risk for fall and the physician ordered a tab alarm. LVN 9 stated Resident 649 had a tendency to get out of bed and take off his bed alarm. LVN 9 stated Resident 649's bed alarm need to be next to the resident at all times so it can alert staff when resident attempts to get out bed and prevent falls.
During an interview on 05/04/21 at 10:47 AM, CNA 7 stated Resident 649 had removed the resident's alarm twice today. CNA 7 stated Resident did have a sitter in the morning but not sure what is the sister schedule for this shift.
During an observation on 05/05/21 at 9:19 AM, Resident 649 was trying to put on his clothes on the the resident was alone in the room. A concurrent interview was conducted; Resident 649 was confused to place, time. date and stated he wanted to go back home.
A review of the facility's Policy Statement, titled Managing Falls and Fall Risk, dated 3/2018, indicated the facility staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize the complications from falling.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide sufficient nursing staff to provide range of motion, application of splints (material used to restrict, protect, or immobilize a pa...
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Based on interview and record review, the facility failed to provide sufficient nursing staff to provide range of motion, application of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), and ambulation to 129 residents requiring a Restorative Nursing Assistant (RNA, nursing aide program that helps residents to maintain their function and joint mobility) program.
This deficient practice had the potential to decrease the residents' range of motion and mobility, which could affect the residents' overall function.
Cross reference F688
Findings:
A review of the facility's policy entitled, Rehabilitative Nursing Care, revised in July 2013, indicated the facility's rehabilitation nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. The policy indicated the program included assisting residents to carry out prescribed therapy exercises.
During an interview on 5/4/21, at 8:32 AM, the Director of Staff Development (DSD) stated there were two RNA staff in Station 2's subacute (area of the facility where individuals require more intensive services) area and two RNA staff in the skilled nursing area each day.
A review of the May 2021 projected staff calendar for Station 2's subacute indicated one RNA was scheduled on 5/3/21, 5/4/21, 5/5/21, and 5/6/21.
During an interview on 5/4/21, at 8:42 AM, Restorative Nursing Assistant 1 (RNA 1) stated she was the only RNA staff for Station 2's subacute on 5/3/21 and 5/4/21. RNA 1 stated the RNA's work schedule included 4-days on and 2-days off. RNA 1 stated two RNA staff worked two days per week. RNA 1 stated RNA staff's responsibilities included obtaining residents' weekly and monthly weights and performing range of motion exercises for 40 subacute residents. RNA 1 stated 24 of 40 residents were seen on 5/3/21 for range of motion during the 8-hour workday. RNA 1 stated Station 2's subacute required at least two RNA staff each day to prevent residents from developing contractures (deformity and joint stiffness).
During an interview on 5/4/21, at 9:06 AM, the DSD stated it was important for residents to obtain RNA services to prevent contractures. The DSD described contractures as painful and can make care difficult for staff.
A review of the facility's projected staff calendar for Station 1, 3, 4, 5 and 6 (skilled nursing area) for the month of May 2021 indicated one RNA was scheduled on 5/3/21, 5/4/21, 5/5/21, and 5/6/21.
During an interview on 5/4/21, at 9:25 AM, RNA 2 stated RNA's responsibilities in the skilled nursing area included obtaining residents' weekly and monthly weights, performing range of motion exercises for 89 residents, and assisting residents with a feeding program. RNA 2 stated she was the only RNA scheduled on 5/3/21. RNA 2 stated that residents can have multiple physician's orders for range of motion to the arms and legs, splint application, and ambulation. RNA 2 stated being able to provide RNA services for 16-20 residents per day but unable to complete RNA sessions with all 89 residents alone. RNA 2 stated the facility used to provide one RNA for each nursing station, totaling at least 4-5 RNA staff per day in the skilled nursing area, from Monday to Friday. RNA 2 stated that it was important for residents to receive RNA services to prevent contractures and decline in function.
During an interview on 5/5/21, at 2:41 PM, the DSD reviewed the skilled nursing staffing, which was posted in the facility for 5/3/21. The facility's posted staff indicated there were two RNA staff for 5/3/21. The DSD stated that there was only one RNA staff on 5/3/21. The DSD stated that RNA 5 was pulled from RNA to perform Certified Nursing Assistant (CNA) duties due to staffing shortage.
During an interview on 5/6/21, at 11:59 AM, Minimum Data Set Assistant (MDS 2) stated MDS 2's other role was the RNA Supervisor. MDS 2 stated that the facility did not have enough staff since the RNA staff were being pulled to perform CNA work.
A review of the facility's policy, titled, Staffing, revised April 2007, indicated the facility maintains adequate staffing on each shift to ensure that our resident's needs and the services are met.
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** d. A review of Resident 146's Face Sheet, indicated the facility admitted the resident on 3/23/21 with diagnoses of chronic resp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. A review of Resident 146's Face Sheet, indicated the facility admitted the resident on 3/23/21 with diagnoses of chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen) and dependence on ventilator (a machine that provides mechanical ventilation by moving breathable air into and out of the lungs).
A review of Resident 146's History and Physical Examination, dated 3/24/21, indicated resident was admitted with tracheostomy tube (a tube inserted in the neck below the vocal cords for breathing) and percutaneous endoscopic gastrostomy tube (PEG, a flexible feeding tube placed into the stomach).
A review of Resident 146's medical record titled Patient Care Plan: Psychotropic Medication, dated 3/23/21, indicated care plan did not include Ativan and did not include any non-pharmacological approach to address the behavior of tube pulling.
A review of Resident 146's MDS, dated [DATE], indicated resident had severe impairment for daily decision making and required extensive assistance for activities in daily living (ADLs such as transferring, dressing, toilet use and personal hygiene).
A review of Resident 146's Physician Orders, dated 4/30/21, indicated an order for the resident to receive Ativan 0.5 milligrams every six hours as needed for anxiety as manifested by pulling of medical equipment or tubing for a period of 14 days.
During an observation on 5/3/21, at 10:45 p.m., Resident 146 was lying in bed with eyes closed and with calm and even breathing.
During an interview on 5/6/21, at 2:47 p.m., Registered Nurse 1 (RN 1) was unable to provide any documentation that staff routinely used non-pharmacological intervention to prevent Resident 146 from pulling his tubes.
During an interview on 5/6/21, at 4:14 p.m., Registered Nurse 6 (RN 6) stated that she understood the importance of psychotropic medication review because sometimes residents don't need it and medication is given to them to control their behavior.
Based observation, interview and record review, the facility failed to ensure 4 of 5 sampled residents (Residents 96, 95, 117 and 146) were free of unnecessary medications.
a. For Resident 96, the resident was not provided non pharmacological (non-medication options) interventions for inability to sleep, and all hours of sleep were not measured during the day, evening and nights while receiving Trazodone (a medication used to relieve falling or remaining asleep) for inability to sleep.
This deficient practice had resulted in Resident 96's hours of sleep were not counted properly which had the potential to result in adverse side effect (untoward effect or reaction) to the medication.
b. For Resident 95, the resident's gradual dose reduction (GDR, slowly reducing the frequency and dose of drug) was not performed while receiving Seroquel (medication that affects mental, mood and behavior).
This deficient practice placed Resident 95 at risk of receiving unnecessary medications that could result in adverse (harmful) side effects and complications to its use.
c. For Resident 117, a GDR was not performed while the resident was receiving Zyprexa (medication that affects mental, mood and behavior).
This deficient practice placed Resident 117 at risk of receiving unnecessary medication that could result in adverse side effects and complications to its use.
d. For Resident 146, non-pharmacological approaches to address the behavior of pulling of medical tubing were not implemented prior administration of Ativan (medication to relieve anxiety [feeling fear of the unknown) to the resident.
This deficient practice placed Residents 146 at risk for developing adverse side effect of psychotropic medication.
Findings:
a. A review of Resident 96's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure ( inadequate exchange of oxygen in the respiratory system) and depression.
A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 2/26/21, indicated Resident 96 does not speak, sometimes able to express needs and wants. The MDS indicated Resident 96 had severe cognitive (ability to think and reason) impairment and required total assistance with one person assistance on bed mobility and personal hygiene.
A review of the Resident 96's Physician's Order, dated 3/30/21, indicated to administer Trazadone 50 milligrams (mg) daily at bedtime for major depressive disorder manifested by inability to sleep.
During an observation on 5/3/21 at 9:26 AM Resident 96 was observed awake with eyes open, unable to talk and does not follow commands.
During an observation and interview on 5/6/21 at 12:31 PM, Licensed Vocational Nurse 6 (LVN 6) stated Resident 96 was non verbal and sometimes yells out but the resident does not follow commands. Resident 96 was observed calm, awake eyes open.
During an observation on 5/04/21 09:12 AM , 5/04/21 at 11:29 AM, 5/05/21 at 8:53 AM, 5/6/21 at 8:16 AM. and 5/06/21 at 2:36 PM, Resident 96 was observed asleep.
During a concurrent interview with (LVN 3) and review of Resident 96's Physician Order and the Medication Administration Record (MAR) on 5/6/21 at 8:16 AM, the MAR indicated Resident 96's hours of sleep was monitored during the evening and night shift and not during the day shift. LVN 3 stated there was no documented evidence a non pharmacological intervention was provided prior to administration of Trazadone. LVN 3 stated it was important to know the total hours of sleep during all shifts to evaluate if the resident need the Trazadone.
A review of the MAR indicated Resident 96 had the following hours of sleep on the following dates:
5/1/21 evening shift-8 hours and night shift-2 hours total 10 hours
5/2/21 evening shift-1 hour and night shift 5 hours-total 6 hours
5/3/21 evening shift-1 hour and night shift-5 hours total 6 hours
5/4/21 evening shift-5 hours and night shift 5 hours-total 10 hours
5/5/21 evening shift-2 hour and night shift-6 hours total 8 hours
5/6/21 evening shift-not documented hours and night shift 6 hours-unknown hours
A review of the Psychotropic Assessment, dated 3/30/21, indicated Resident 96 was confused. The assessment indicated non pharmacological interventions included to provide verbal cues, remove stimuli and reorientation.
A review of the plan of care, titled Psychotropic Medications, dated 3/30/21, indicated Resident 96 required the use of Psychotropic Drugs for depression. To prevent ASE (Adverse Side Effect) to the medication, Resident 96 will evaluate behavior and medication as necessary and monitor behavior by hashmarks every shift.
b. During an observation on 5/3 21, at 12 p.m., Resident 95 was sitting in bed and eating lunch. The resident ate 100% of her lunch meal. The resident was calm without agitation and striking-out behavior.
A review of Resident 95's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD- progressive disease, osteo arthritis (inflammation of one or more joints, which results in pain, swelling, stiffness, and limited movement) and heart disease.
A review of the MDS dated [DATE], indicated Resident 95 had short and long-term memory problems. The resident was severely impaired in cognitive skills for daily decision-making, usually able to understand others and usually made herself understood. The MDS indicated the resident required limited assistance to extensive assistance from the staff for most activities of daily living. The MDS Sections D and E for Mood, and Behavioral Symptoms indicated the resident did not have any behavioral symptoms or concerns.
A review of the Physician's Order dated 7/31/20, indicated to administer Seroquel 12.5 milligrams (mg) daily by mouth at bedtime for schizophrenia (a group of brain disorders in which people interpret reality abnormally) manifested by screaming and yelling.
A review of the Monthly Psychotropic Summary Sheet dated from 1/1/21 to 4/30/21, indicated Resident 95 had aggressive behavior and episodes of refusing care are as follows:
1/1/21 to 1/31/21, there were 58 episodes
2/2/21 to 2/28/21, there 54 episodes
3/1/21 to 3/31/21, there 77 episodes
4/1/21/to 4/30/21, there 47 episodes.
During an interview with LVN 7 on 5/3/21, at 4 p.m., she stated that Resident 95's behavioral monitoring was aggressive behavior and refusing care. LVN 7 stated that Resident 95 did not exhibit any episodes of screaming and yelling. LVN 7 was also asked if an attempt was made for a gradual dose reduction (GDR) for Seroquel, LVN 7 stated that she will call the physician for clarification of the specific behavior/ indication and for the gradual dose reduction of Seroquel.
c. During an observation on 5/3/21, at 3:30 p.m., Resident 117 was observed ambulating along the hallways. The resident was quiet and calm.
A review of the resident's 117's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included hypertensive heart disease (high blood pressure) and lack of coordination.
A review of the MDS, dated [DATE], indicated the resident completed the brief interview for mental status without recall problems, had clear speech, was able to understand others and made herself understood. The MDS indicated the resident required supervision from the staff for most activities of daily living.
A review of the Physician's Order dated 3/18/20, indicated to administer Zyprexa 5 milligrams (mg) by mouth every hour of sleep (qhs) for schizophrenic disorder manifested by (m/b) talking to herself and paranoid thinking being watched by others.
During an interview with the LVN 7 on 5/4/21, at 10 a.m., she stated that no gradual dose for the reductions for the Zyprexa were attempted since the medications were ordered in 2020.
On 5/4/21, 10:30 a.m., during an interview with CNA 7, she stated the resident did not present any danger to peers and staff.
During an interview with LVN 6 on 5/4/21, at 11 a.m., she stated there was no documented evidence a gradual dosage reduction for the Zyprexa was attempted and no documentation that a gradual dosage reduction was clinically contraindicated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation interview and record review, the facility failed to ensure the medication error rate was not 5 percent or g...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation interview and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. There were 2 errors observed during medication pass observation with 25 opportunities which yield 7.69% error rate.
a. For Resident 103, the Vitamin C ( a vitamin supplement) morning dose was omitted from the medication administered.
This failure had the potential to cause a Vitamin C deficiency in resident 103 which could result in delayed wound healing, bruising, and painful and swollen joints.
b. For Resident 101, the gastric tube (a tube surgically inserted into the stomach to deliver fluids and medications) was not flushed prior to medication administration.
This deficient practice had the potential for the GT to clogged and adverse (undesired effect) drug reaction to the medications administered.
Findings:
a. A review of Resident 103's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cutaneous abscess of the lower limb (skin infection with pus on the lower leg).
During a medication pass observation on 5/4/21 at 7:45 a.m., Licensed Vocational Nurse 1, (LVN 1) administered medication to Resident 103. LVN 1 did not administer Vitamin C to Resident 103.
A review of Resident 103's electronic medication record (eMAR), indicated the Physician ordered to administer Vitamin C 500 mg liquid twice a day (BID) to Resident 103.
During an interview on 5/4/21, at 9:05 a.m., LVN 1 stated, she did not see the order for Vitamin C 500 milligrams on the EMAR during the medication administration therefore the medication was not given.
b. A review of Resident 101's Facesheet (admission Record) indicated that the facility admitted Resident 101 on 7/12/19. Resident 101's diagnoses included hypertension (high blood pressure), and epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain).
A review of Resident 101's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 3/8/21 indicated Resident 101 required total dependence from staff for bed mobility, dressing, eating, toilet use and personal hygiene.
During a medication pass observation on 5/4/21, at 8:58 AM, License Vocational Nurse 1 (LVN 1) did not flush the tube feeding with 15 ml to 30 ml of water before administering Docusate Sodium (stool softener) 100 milligram (mg) 2 tablets.
During an interview on 5/4/21, at 9:38 AM with LVN 1, LVN 1 stated she did not remember if she flushed the tube feeding with water before she administered the medication. LVN 1 also stated it was important to flush the tube feeding with water before administering medication to make sure the tube was patent and with no residuals.
During an interview on 5/6/21, at 11:26 AM with Director of Nursing (DON), she stated tube feeding should be flushed with water prior to giving medications. DON also stated it was important to flush the tube feeding with water so that the feeding would not mix with the medication, to cleanse the tube and to made sure the tube was patent before administering medication.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications through an Enteral Tube, the P&P, indicated dated March 2015, the P&P indicated to flush tubing with 15 to 30 ml warm sterile water (or prescribed amount).
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 ensure all drugs and biological used in the facility 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 all drugs and biological used in the facility are labeled in accordance with professional standards and failed to remove expired medications from medication carts and storage rooms.
a. Resident 192's medication was found outside of its protective packet and with out an open and expiration dates.
b. Resident 71's medication was found stored past the use by date.
These failure had the potential for Resident 192 and Resident 71 receiving medications that past the use by date and were not stored properly and placed the residents at risk for receiving ineffective medications.
c. Station 6's medication cart and Medication Storage room [ROOM NUMBER] had expired medications.
These deficient practices had the potential for residents to receive expired medication which can affect the residents' well-being.
Findings:
a During a concurrent inspection of the medication cart (Med cart 1-1) and interview with Licensed Vocational Nurse 1 (LVN 1) on 5/5/21, at 2:08 pm, one Ipratropium Bromide 0.5 mg /Albuterol Sulfate 3 mg foil packet (a medication used to open up air passages in the lungs, and help control symptoms of lung diseases , such as asthma) for resident 192 was found opened with four of five vials/unit doses left. These vials had fallen out of their protective foil packet without the open date or expiration date was written on package. LVN 1 stated the medication packet for Resident 192 should have been dated with date the foil packet was opened and use by date.
A review of the Ipratropium Bromide 0.5 mg /Albuterol Sulfate 3 mg foil packet instructions, under the storage condition section, indicated that the unit dose should remain stored in protective foil pouch. Once removed from foil pouch, the individual vials should be used with in one week.
b. During the same inspection of Med Cart 1-1 with LVN 1, Resident 71's Humilin R insulin (medication to treat high blood sugar levels in patients with diabetes) was found opened, with an open date of 3/19/21. LVN 1 stated
the insulin for Resident 71 was good for 28 days after opening and should have been discarded so the resident would not receive old or bad medicine.
A review of the Humilin R instructions, dated November 2019, under How Should I store Humilin R, indicated opened vials should be thrown away at 31 days, even if there is still insulin left in the vial.
c. During an observation on 5/05/21 at 3:30 PM, the following medications were found in the medication cart of Station 6:
1. Metoclopramide 10 mg tab (used to treat the symptoms of slow stomach emptying in patients with diabetes) expired on 4/22/21. The packet was not marked Expired and was stored together with the other medications.
2. Ondansentron HCL 4 mg tab (used to prevent nausea and vomiting) expired on 2/22/21 and was in the drawer. The medication was marked, Expired.
3. Ferrous Sulfate 220 mg/5 ml (Gerjcare Iron Supplement Liquid, used to treat iron deficiency), a medication intended for multiple use was open and not dated.
During a subsequent interview with Licensed Vocational Nurse 17 (LVN 17), she stated that expired medications should be removed from the medication cart immediately and medications that have been opened should be dated accordingly.
During an interview on 5/06/21 at 8:22 AM, the Director of Nursing (DON) stated that licensed nurses should check all medications in the medication cart every shift and should remove all medications that are expired.
During an observation at the Medication Storage room [ROOM NUMBER] on 05/06/21 at 08:45 AM, four Major-Prep Hemorhoidal Ointments (used to temporarily relieve swelling, burning, pain, and itching caused by hemorrhoids) and four Geri-Care Nephro Vitamins that expired on 11/2020 and 7/2020 respectively were kept in the storage room for use.
During an interview on 5/06/21 at 10:01 AM, the Central Supply Supervisor stated that he stocks up the medication storage room with non-prescribed medications. He stated that medications that are expired should be removed immediately and properly discarded.
A review of the facility's policy, titled Storage of Medications, revised in April 2007, indicated that the nursing staff shall be responsible for maintaining medication storage and the facility should not use discontinued, outdated, or deteriorated biological.
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 that food items were stored under sanitary conditions as indicated in the policy and procedure by failing to:
1. Ensur...
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Based on observation, interview, and record review, the facility failed to ensure that food items were stored under sanitary conditions as indicated in the policy and procedure by failing to:
1. Ensure not to store a dented food can in the pantry.
2. Ensure to maintain the floors behind standing refrigerators clean.
These deficient practices had the potential for residents to be at risk for contracting food-borne illnesses.
Findings:
During an initial tour of the kitchen and an interview on 5/3/2021 at 8:35 am, the Director of Nutrition/Environment stated there was one 110 ounce (a unit of weight) tomato dented can stored with other non-dented cans on the rack, and there was an accumulation of dust particles on floors behind standing refrigerators. The Director of Nutrition/Environment stated the dented cans should be separated from the non-dented cans.
A review of the facility's Food Service Management policy and procedure dated 2018, indicated damaged cans and packages to be returned to Vendor and to have an inspection system of cans and packages that were delivered to ensure safety of foods to residents, monthly check of cans and packages in storerooms.
A review of the facility's Cleaning Procedures policy dated with the year of 2018, indicated floors were cleaned and maintained to avoid accumulation of dirt, food particles, dust, grime, grease, water spots and vermin.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to develop, implement, and evaluate the appropriate plan of action to correct identified quality deficiencies by failing to:
1. ...
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Based on observation, interview, and record review, the facility failed to develop, implement, and evaluate the appropriate plan of action to correct identified quality deficiencies by failing to:
1. Ensure residents at risk of developing or with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints that could cause pain) were provided range of motion (ROM) exercises by the RNA (Restorative Nursing Assistant).
The 11 of 11 sampled residents with contractures or at risk for developing contractures were not provided ROM exercises and/or placed assistive device to prevent contractures.
There were 36 residents out of 107 residents developed contractures at the facility.
This deficient practice had resulted in severe contractures and potential to result in additional contractures or worsened contractures of the residents with and at risk in developing contractures.
2. Ensure residents with pressure injuries (a skin tissue injury that result due to prolonged unrelieved pressure) were repositioned at least every two hours and provided pressure relieving devices.
There were 7 of 10 sampled residents that were not repositioned or provided pressure relieving device and proper bed settings according to the weight.
There were a total of 35 residents in the facility with pressure injuries excluding Stage 1 (non blanchable intact skin redness) pressure injury at the facility.
This deficient practice had the potential to result in recurrence of healed pressure injury, development of new pressure injury and worsened pressure injuries.
3. Ensure the facility's internet and phone lines connections were in good functioning condition for the facility to receive phone calls and use the internet services.
Family members and the responsible parties of Residents 91, 75, and 187 who were interviewed, stated it was difficult to get an update or communicate with the residents because the facility did not answer the phone or phone connections got disconnected.
This deficient practice had resulted in the residents not to practice their rights to be informed about their health care conditions and/or allow the responsible parties to assist with the healthcare decisions when the residents does not have the capacity to decide for themselves.
Cross reference to F552, F686 and F688
Findings:
1. According to the survey findings there were 11 sampled residents that were not provided the range of motion exercises or provided a device to prevent contractures.
A review of the Residents and Conditions of Residents, a Centers of Medicare and Medicaid Form 672 ( CMS 672, a report of the current conditions of the residents at the time of the recertification survey), submitted by the facility on 5/3/2021, indicated 36 residents developed contractures at the facility out of 107 residents with contractures.
During an interview with the Administrator (ADM) and the Director of Nursing (DON) regarding the Quality Assurance Program Improvement (QAPI) of the facility on 5/7/2021 at 1:03 p.m., the DON stated the facility started to implement action to prevent contractures. The DON stated there was no written plan of action at this time to indicate specific actions to be implemented and who would be responsible to ensure the actions were implemented. The DON also stated there had been shortage of staff beginning in the year due to the Corona virus -19 (COVID-19 a severe infection primary affects the respiratory system) pandemic (a worldwide infection) that resulted in the shortage of staff which the facility had identified as the problem.
2. According to the current survey findings there were 7 of 10 sampled residents who were not repositioned or provided pressure relieving device and proper bed settings according to the weight.
During an interview on 5/7/2021 at 1:03 pm, the DON stated a plan of action was developed to address the concerns about the resident's pressure injuries but there was no one specific staff assigned to monitor and oversee and evaluate if the plan of action was implemented to determine if the actions were implemented accordingly.
The written plan of action and evaluation of the action was requested from the facility on 5/7/2021 at 1:03 p.m., and was not provided.
3. During the survey, three family/responsible parties interviews of Residents 187, 91, and 75 stated the phone service was poor and no one answered the phone calls or phone connections gets disconnected.
During an interview on 5/7/2021 at 1:47 pm, DON stated the phone line and internet issues were discussed during the quarterly meeting in January but there is still a problem with the phone calls not answered or dropped.
During an interview on 5/7/2021 at 12:30 pm, the ADM stated she was aware of the issues about the internet problem in the facility which caused the incoming calls to drop or get disconnected when the internet connection was lost, which could be the reason why the phone calls of the responsible parties were lost or not answered.
A review of the policy and procedure, titled Quality Performance and Quality Improvement Program-Governance and Leadership, dated 3/2020, indicated the responsibilities of the QAPI Committee were to:
a. Collect and analyze performance indicator data and other information.
b. Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services.
c.Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process.
d.Utilize root cause analysis to help identify where identified problems point to underlying systematic problems.
e.Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care.
f.Establish benchmarks and goals by which to measure performance improvement.
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** e. A review of Resident 103 Face Sheet indicated the facility admitted the resident on 12/15/2017 and readmitted the resident on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. A review of Resident 103 Face Sheet indicated the facility admitted the resident on 12/15/2017 and readmitted the resident on 2/10/2021 with diagnosis of dependence on renal dialysis.
A review of Resident 103's Renal Dialysis care plan dated 4/21/2021 indicated the resident's dialysis access catheter was on the resident's right upper chest and for the staff to inspect the dressing for signs and symptoms of infection.
During an interview on 5/4/2021 at 12:20 pm LVN 1 stated Resident 103 did not have a dressing over the insertion site. LVN 1 stated there should be Dressing on to prevent infection.
A review of the facility's policy and procedure titled, Hemodialysis Access Care, dated 2010, indicated that the access site was to be kept clean at all times.
7. During an observation on 5/5/2021 at 9:20 am, the Maintenance supervisor did not remove his isolation gown when he exited room A (Room A is designated a yellow zone room).
During an interview on 5/5/2021 at 9:28 am, Maintenance supervisor stated he was supposed to remove the isolation gown before he left room A to prevent the potential spread of COVI-19.
A review of the facility's mitigation plan with a revised dated of 4/12/2021 indicated, staff would doff PPE (personal protective equipment) when exiting a yellow zone area.
3. A review of Resident 19's Facesheet (admission Record) indicated the facility readmitted Resident 19 on 4/31/2021 with diagnosis of gastro esophageal reflux disease (GERD - chronic condition in which stomach contents rise up into the tube connecting the mouth and stomach).
A review of Resident 19's History and Physical dated 4/11/2021, indicated Resident 19 did not have the capacity to understand and make decisions.
A review of Resident 19's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 1/25/2021 indicated Resident 19 required total dependence from staff for bed mobility, dressing, toilet use and personal hygiene.
A review of Resident 19's Isolation Precaution care plan dated 5/1/2021, indicated the resident was on contact isolation (used to prevent the spread of diseases that can be spread through contact), and the interventions were to maintain isolation as indicated, and provide instructions to family and visitors and staff on proper infection control measures.
During an observation and interview on 5/3/2021, at 2:04 pm, Registered Nurse 6 (RN 6) stated Resident 19 was in the yellow zone and there were no gowns readily available outside the room and stated PPE should be maintained outside Resident 19's room for anyone who should enter the room can don (put on) proper PPE. RN 6 also stated it was important for the staff to wear proper PPE to prevent spread of infection.
During an interview on 5/6/21, at 11:25 am, the Director of Nursing (DON), stated PPE supplies should be replenished and should be available and maintained in the isolation cart outside Resident 19's room.
A review of the facility's policy and procedure titled, Isolation - Initiating Transmission-Based Precautions, with a revised date of August 2019, indicated to ensure PPE was maintained outside the resident's room for anyone entering the room could apply the appropriate equipment.
4. A review of Resident 76's Face Sheet indicated the facility readmitted Resident 76 on 8/26/2020 with diagnoses of dysphagia (difficulty swallowing), neuromuscular dysfunction of bladder (condition in which problems with the nervous system affect the bladder and urination), and GERD.
A review of Resident 76's MDS dated [DATE] indicated the resident was severely impaired in cognitive skills for daily decision making The MDS indicated Resident 76 required total dependence from staff for bed mobility, dressing, eating, toilet use and personal hygiene.
A review of Resident 76's Physician's Order dated 4/3/2021, indicated for the resident to receive diabetic source AC (formula) at 70 cubic centimeter (cc, measurement of volume) per hour.
During an observation and interview on 5/3/2021, at 10:49 am, RN 6 stated Resident 76's enteral feeding tube's label was undated. RN 6 stated the enteral feeding (given through a tube into the stomach) tubing should be changed every 24 hours and must have a date for the staff to know when would be the next time to change to prevent infection.
During an interview on 5/5/2021, at 2:15 pm, the DON stated if Resident 76's enteral feeding tube was undated and not documented, it meant it was not done. DON stated the facility's Policy and Procedure for Infection Control Standards indicated for tubing used for enteral tube feeding to be changed every 24 hours.
A review of the facility's undated policy and procedure titled, Infection Control Standards, indicated for the tubing used for enteral nutrition administration would be changed every 24 hours.
5. A review of Resident 35's Face Sheet indicated the facility readmitted Resident 35 on 8/22/2019 with diagnoses of diabetes (a condition that affects the way the body processes blood sugar), and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood).
A review of Resident 35's MDS dated [DATE], indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 35 required total dependence from staff for bed mobility, dressing, eating, toilet use and personal hygiene.
A review of Resident 35's Physician's Order dated 4/26/2021, indicated to change the resident's intravenous (IV, via vein) administration set (tubing) every three days and to administer Invanz 1 gram (medication to treat infection) every 24 hours for seven days for urinary tract infection (UTI - an infection in any part of your urinary system) until 5/2/2021.
A review of Resident 35's untitled care plan dated 5/4/2021, indicated a peripheral catheter (IV line) was inserted on the resident's left hand on 4/26/2021.
During an observation and interview on 5/3/2021 at 10:31 am, RN 6 stated Resident 19's peripheral intravenous label was dated 4/26/2021. RN 6 stated the resident's IV site should be changed every 72 hours and it was seven days Resident 19 had the peripheral IV on the resident's left hand. RN 6 stated it was important to change the peripheral IV site to avoid infection.
During an interview and a record review of Resident 35's medical record on 5/6/21 at 11:17 am, DON stated the resident's peripheral IV site should be changed within 48 to 72 hours after insertion.
A review of the facility's undated policy and procedure titled, Infection Control Standards, indicated peripheral catheters would be changed every 48 to 72 hours or per manufacturer's guidelines and immediately upon suspected contamination or complication.
6a. During a review of Resident 101's Face Sheet indicated the facility admitted Resident 101on 7/12/2019 with diagnoses of hypertension (high blood pressure), and epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain).
A review of Resident 101's History and Physical dated 8/23/2020, indicated Resident 101 did not have the capacity to understand and make decisions.
A review of Resident 101's Physician's Order dated 12/9/2020 indicated for the resident to receive diabetic source AC.
During a review of Resident 101's MDS dated [DATE] indicated Resident 101 required total dependence from staff for bed mobility, dressing, eating, toilet use and personal hygiene.
During an observation and interview on 5/4/2021 at 8:58 am, Licensed Vocational Nurse 12 (LVN 12) stated she did not rinse the used syringe after giving medication to Resident 101 via enteral tube.
During an interview on 5/4/21 at 9:41 LVN 12 stated she was supposed to rinse Resident 12's syringe after she used it. LVN 12 stated it was important to rinse the syringe after use because it might be dirty and could cause infection.
6b. A review of Resident 177's Face Sheet indicated the facility readmitted Resident 177 on 3/22/2021 with diagnoses of hypertension and dysphagia (difficulty swallowing).
A review of Resident 177's Physician's Order dated 3/22/2021 it indicated for the resident to receive diabetic source AC.
A review of Resident 177's MDS dated [DATE] indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 177 required total dependence from staff for bed mobility, dressing, eating, toilet use and personal hygiene.
During an observation on 5/5/2021at 9:05 am, inside Resident 177's room, LVN 13 stated she did not rinse Resident 177's syringe after she administered the medication via enteral tube.
During an interview on 5/5/2021 at 9:08 am LVN 13 stated her practice was to rinse Resident 177's at the end of her shift and not after every use.
During an interview on 5/6/2021 at 11:26 am DON stated the syringes used in giving medications should be cleaned or rinsed after every use to prevent infection.
A review of the facility's undated policy and procedure titled, Infection Control Standards, indicated strict aseptic technique would be used when changing tubing connections.
2. During an observation on 5/3/2021, at 9:36 am, there were soiled blue dust mops in an uncovered yellow container upon entry to the soiled laundry room.
During an interview on 5/3/2021, at 1:25 pm, Infection Prevention Nurse 1 (IPN 1, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), stated that any soiled laundry, including the blue dust mops, should be in closed containers. IPN 1 stated that it was important for soiled laundry to be secured in a closed container or closed bags to prevent cross-contamination.
A review of the facility's policy, titled Laundry and Bedding, Soiled, with a revised July 2009, indicated to place contaminated laundry in a bag or container at the location where it was used.
Based on observation, interview, and record review, the facility failed to provide a safe, sanitary environment to help prevent the spread of infections during the Coronavirus-19 (COVID-19, a respiratory illness that can spread from person to person) as indicated in the facility's policy and procedure by failing to:
1. Ensure Resident 75's call light (device used by a patient to signal his or her need for assistance from professional staff), was disinfected after the call light was found on the floor.
2. Ensure contaminated dust mops were covered.
3.Ensure to have personal protective equipment (PPE refers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) readily available for staff and visitors to use for Resident 19 in the yellow zone (unit for residents who have been in close contact with known cases of COVID-19) .
4. Ensure licensed nurses label the enteral feeding (given through a tube into the stomach) tubing for Resident 76.
5. Ensure licensed nurses change Resident 35's intravenous (IV, via vein) administration set.
6. Ensure licensed nurses used a clean or aseptic technique (method used to prevent contamination with germs), when handling syringes during medication administration for Resident 101 and Resident 177.
7. Ensure staff doffed (removed) contaminated PPE when exciting a yellow zone room.
8. Ensure Resident 103's hemodialysis access (hallow tube inserted into a large vein for exchanging blood to and from a blood filtering machine and a patient) site was covered with a dressing (bandage, patch, a piece of soft material that covers and protects an injured part of the body).
These deficient practices had the potential to spread infections between residents, staff, and visitors.
Findings:
1. During an observation and interview on 5/07/2021, at 8:45 am, Certified Nursing Assistant 8 (CNA 8) picked Resident 75's call light that was lying on the floor behind the resident's head of the bed and placed it back to the resident without cleaning or disinfecting the call light. CNA 8 stated the call light should be cleaned before placing it back on the resident's bed.
A review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy and procedure, with a revised date of July 2014, indicated the resident care equipment, including reusable items and durable medical equipment would be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Blood borne Pathogens Standard.
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
- • 32% 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, 4 harm violation(s), $194,891 in fines, Payment denial on record. Review inspection reports carefully.
- • 184 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $194,891 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 Inland Valley Care And Rehabilitation Center's CMS Rating?
CMS assigns INLAND VALLEY CARE AND REHABILITATION CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Inland Valley Care And Rehabilitation Center Staffed?
CMS rates INLAND VALLEY CARE AND REHABILITATION CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 32%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Inland Valley Care And Rehabilitation Center?
State health inspectors documented 184 deficiencies at INLAND VALLEY CARE AND REHABILITATION CENTER during 2021 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, and 178 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Inland Valley Care And Rehabilitation Center?
INLAND VALLEY CARE AND REHABILITATION CENTER 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 221 certified beds and approximately 224 residents (about 101% occupancy), it is a large facility located in POMONA, California.
How Does Inland Valley Care And Rehabilitation Center Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, INLAND VALLEY CARE AND REHABILITATION CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Inland Valley Care And Rehabilitation Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.
Is Inland Valley Care And Rehabilitation Center Safe?
Based on CMS inspection data, INLAND VALLEY CARE AND REHABILITATION CENTER 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 Inland Valley Care And Rehabilitation Center Stick Around?
INLAND VALLEY CARE AND REHABILITATION CENTER has a staff turnover rate of 32%, 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 Inland Valley Care And Rehabilitation Center Ever Fined?
INLAND VALLEY CARE AND REHABILITATION CENTER has been fined $194,891 across 5 penalty actions. This is 5.6x the California average of $35,028. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Inland Valley Care And Rehabilitation Center on Any Federal Watch List?
INLAND VALLEY CARE AND REHABILITATION CENTER 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.