BRENTWOOD HEALTH CARE CENTER
For profit - Limited Liability company
59 Beds
NAHS
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
48/100
#536 of 1155 in CA
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Photo by Brentwood Health Care Center
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Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Brentwood Health Care Center has a Trust Grade of D, indicating below-average performance with some concerns about care quality. It ranks #536 out of 1,155 facilities in California, placing it in the top half overall, and #91 out of 369 in Los Angeles County, meaning there are only a few local options that are better. The facility's trend is improving, having reduced its issues from 14 in 2024 to just 1 in 2025. Staffing is average with a turnover rate of 42%, similar to the state average, and there have been no fines reported, which is a positive sign. However, there have been serious concerns, including critical failures to control COVID-19 spread and food safety issues, such as expired food being stored improperly, which could pose health risks to residents. While there are strengths in staffing stability and quality measures, families should weigh these issues carefully when considering this facility.
- Trust Score
- D
- In California
- #536/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 42% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- 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
- 82 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Top 46%
Review needed
14 → 1 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 14 issues
2025: 1 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (42%)
6 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near California average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 42%
Near California avg (46%)
Typical for the industry
Chain: NAHS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 82 deficiencies on record
1 life-threatening
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
Deficiency F0774
(Tag F0774)
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 arrange and confirm transportation to a doctor's appointment for one...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to arrange and confirm transportation to a doctor's appointment for one of three sample residents, (Resident 1).
This deficient practice caused Resident 1's appointment to be changed unnecessarily.
Findings:
A review of the admission record indicated the facility originally admitted Resident 1 on 11/16/2023 and was readmitted [DATE] with diagnoses including presence of right artificial knee joint, diabetes Mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipemia (high fat in the blood), dementia (a progressive state of decline in mental abilities), abnormality of gait (not walking normal), obesity (overweight), vitamin D deficiency (low in vitamin D), overactive bladder (unable to control sudden urges to urinate) and obstructive sleep apnea (a sleeping disorder).
A review of Resident 1's history and physical (H&P- the doctor's physical assessment and plan of care) dated 3/4/2025 indicated Resident 1 had a surrogate decision maker. and that Resident 1 had an appointment scheduled to see the orthopedic (bone) doctor on 3/7/2025.
A review of Resident 1's minimum data set (MDS-a resident assessment) dated 3/8/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was not intact. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) with personal hygiene and bathing. Resident 1 required maximal assistance (helper does more than half the effort) with toileting and transfers (moving between surfaces) from bed to chair. Lastly, Resident 1 required moderate assistance (helper does less than half the effort) with ambulating 10-50 feet using walker.
On 3/19/2025 the California Department of Public Health (CDPH) received a complaint alleging the facility cancelled a doctor's appointment for Resident 1 without notifying the resident representative.
During a concurrent interview and record review on 3/20/2025 at 10:05 a.m. with the social service assistant (SSA), Resident 1's nursing progress note dated 3/7/2025 was reviewed. The nursing progress noted indicated Resident 1 had an appointment with a orthopedic doctor on 3/18/2025. The SSA stated, I documented this appointment when Resident 1 returned from the initial appointment on 3/7/2025. On 3/18/2025 the certified nursing assistant (CNA) came to my office at about 10:50a.m. stating [Resident 1] had an appointment that morning at 10:45a.m. My mistake was I did not have the appointment in my folder, that is how I keep track of them, then I would set up transportation a few days before the appointment, but I did not do that this time. I guess the family was already here to take Resident 1 to the appointment when the CNA told me about the appointment, but I did not know they were here already . I thought Resident 1 had missed the appointment so I called the orthopedic doctor's office and asked if they could push back the appointment to 1:00p.m. and they agreed . SSA stated, After that I contacted our driver to arrange transportation, and the driver agreed to take Resident 1 to the appointment at 1:00 p.m. After this the resident representative (RR) was already standing in front of my office yelling WHY DID YOU CANCEL THE APPOINTMENT YOU ARE NOT FAMILY and seemed very upset not allowing me to tell her that I did not cancel I just rescheduled then went and complained to the Administrator (Adm). After all of the confusion the RR was still able to take Resident 1 to the appointment at 11:30am and they returned approximately one hour later. The SSA stated, I do think this could have been avoided if I had kept track of the appointment and called the family a few days prior like I normally do to confirm the appointment and transportation .
During an interview on 3/20/2025 at 11:50 a.m. with the director of nursing (DON), the DON stated on 3/18/2025 Resident 1 had a doctor's appointment and transportation had not been set up so the SSA rescheduled the appointment from 10:45 a.m. to 1:00p.m. I think the family thought we cancelled the appointment but when they spoke to the Administrator, they found out it was not cancelled just rescheduled I did not witness the interaction. I am not sure why transportation was not already arranged I did not look into it, I assumed it was resolved because [Resident 1] still went to the appointment .
During an interview on 3/20/2025 at 12:50 p.m. with the resident representative (RR) stated on 3/8/2025 the RR arrived at the facility at 10:30am to take Resident 1 to the ortho appointment scheduled for 10:45 a.m. The RR stated, we scheduled the appointment at that time because it fits my schedule so we would be able to take Resident 1 to the appointment. The RR stated, the SSA was aware of this follow up appointment because we provided them with the appointment date and time when we returned from Resident 1's first appointment on 3/7/2025. The RR stated while they were in the facility on 3/18/2025 waiting to take Resident 1 to the appointment; they got a call from the ortho doctor's office informing them the appointment had been cancelled. The RR then called the Ortho doctor's office and was told the facility cancelled the appointment. The RR stated, That made me upset because we schedule all Resident 1's appointments and no one from the facility communicated with us about cancelling or rescheduling Resident 1's appointment and we were there in the facility. The facility does not know our relationship with the Ortho doctor, we have been late before, and they would still see Resident 1. The RR stated, The facility should not be cancelling and rescheduling appointments without speaking to the responsible party first.
During an interview on 3/20/2025 at 3:30 p.m. the CNA stated, On 3/18/2025 between 10:15a.m. and 10:20 a.m. I had just taken [Resident 1] to the bathroom and put her back into bed when I was notified by the unidentified charge nurse (CN) that [Resident 1] had an appointment at 10:45 a.m. Usually when a Resident has an appointment it is listed n the assignment sheet, but I did not see her appointment on the assignment sheet that morning. After the (CN) told me about the appointment I went to check the appointment book, and I did not see it there, so I went to the [SSA] office to confirm the appointment with the [SSA]. I did see the family arrive to the room around 10:40 a.m.
A review of the facility job description for social service assistant (no date [n.d.]) indicated the social service assistant job duties include:
Arranges residents' appointments including transportation when necessary.
A review of the facility policy and procedures titled Transportation dated 2/2025, indicated,
It is the policy of this facility to assist residents in accessing transportation according to their needs.
RATIONALE: Residents may have appointments outside the facility. While the facility is not obligated to provide this transportation, the facility is expected to help residents evaluate options and access public or private transportation according to their means and abilities to travel safely in the community.
PROCEDURE:
Social Service staff works with other members of the Interdisciplinary Team to determine a resident's need for transportation. A resident may also request assistance with transportation.
Oct 2024
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
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's interdisciplinary team (IDT-- a group of health care professio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility's interdisciplinary team (IDT-- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to ensure that one of 13 sample residents (Resident 53) did not keep medications at the bedside without a physician's order and/or without being assessed to determine if the resident is capable to self-administer medications.
This deficient practice resulted in Resident 53 keeping a white powder like substance inside the medication dispensing cup and self-applying the white powder under the breasts. This deficient also, had the potential for the white powder to be accessed and used by unintended person.
Cross Reference F760
Findings:
During a review of the admission record indicated Resident 53, was admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia (a serious medical condition that occurs when the lungs have trouble loading the blood with enough oxygen and body tissues), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs.), major depressive disorder (A mental health condition that involves persistent feelings of sadness, hopelessness, and a loss of interest in activities), muscle weakness and dysphagia (medical term for swallowing difficulties).
During a review of Resident 53's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 09/21/2024, indicated Resident 5's cognition (The mental ability to make decision of daily living) was intact. The MDS indicated Resident 53 was independent with eating, oral hygiene, and required partial moderate assistance with upper body dressing, was dependent for Toileting hygiene, shower/bathe, lower body dressing, required limited assistance with his activities of daily living.
During a concurrent observation and interview on 10/15/2024, at 7:56 AM, Resident 53's bedside drawer was observed with unlabeled medication dispensing cup and a white powder like substance inside the medication dispensing cup. Resident 53 was asked if she knew what the white powder that was inside the unlabeled medication cup. Resident 53 stated, it is antifungal (medication to treat fungal infection/s) powder and that she applies the powder under her breast.
During an interview on 10/15/2024, at 7:56 AM., Certified Nursing Assistant 5 (CNA5) stated CNA 5 did not know what was in the medicine cup. CNA5 further stated, it looks like a powder the white powdered substance.
During an interview on 10/15/2024 at 8 AM., with the Treatment Nurse 1 (TXN 1), TXN 1 stated TXN 1 did not know what the white powdered substance in the medication dispensing cup on top of Resident 53's bedside drawer was. TXN 1 further stated, the powder in the medication cup is not supposed to be on top of resident's bedside drawer, because it is not labeled and thus unidentifiable. TXN 1 also stated leaving an unlabeled medication cup with an unidentifiable powder in places the Resident at risk of ingesting a white powder that may be unsafe for consumption and if consumed could cause an allergic reaction that could result in anaphylaxis and even death.
During an interview on 10/18/2024 at 4:53 pm with the Director of Nursing (DON), the DON stated, Residents are only allowed for have medications at bedside if they have been assessed to be cognitively intact and have physically demonstrated that they can safely be able to do so and have a physician approval. The DON stated without resident assessment, the medication may be applied/administered incorrectly, placing the resident at risk for skin breakdown, irritation, and or redness. The DON also stated medication at bedside should be secured in a locked container.
During a review of the Physician Orders dated 10/18/2024, indicated no order to apply antifungal powder under Resident 53's breasts.
During a review of the facility's policy and procedures titled Self-Administration of Medication dated 09/2023 indicated, .the IDT, assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the Resident. Policy further states self-administered medications are stored in a safe and secure place, which is not accessible by other Residents .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the residents right to formulate an advanced directive ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the residents right to formulate an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) was recorded for two of 14 sampled residents (Residents 23 and 26).
This deficient practice violated Residents 23 and 26 right to be fully informed of the option to formulate advance directives and had the potential to cause conflict with health care wishes for residents 23 and 26.
Findings:
During a review of Residents 23's admission Record indicated the facility admitted Resident 23 on 3/8/2023 with diagnoses including hyperlipidemia (high level of fats in the blood), hypertension (HTN - elevated blood pressure), and generalized muscle weakness (lack of physical or muscle strength).
During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/9/2024, indicated Resident 23 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills. The MDS indicated Resident 23 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene.
During a review of Resident 23's Advanced directive acknowledgement form dated 3/8/2023 sign portion stated verbal.
During an interview on 10/16/2024, at 8:59 A.M., with Resident 23, Resident 23 stated the facility did not discuss advanced directive information with him.
During an interview and record review on 10/16/2024, at 11:10 AM., with the Social Services Director (SSD), the SSD stated the advanced directive acknowledgement form needs to have the residents' signature to be complete and accurate, the signature of the residents acknowledges the receipt of the information given.
During a review of Residents 26's admission Record indicated the facility admitted Resident 26 on 9/21/2024 with diagnoses including hyperlipidemia, hypertensive chronic kidney disease (a condition where blood pressure damages the kidneys, making it difficult for kidneys to filter blood), and generalized muscle weakness.
During a review of Resident 23's MDS dated [DATE], indicated Resident 26 had intact cognitive skills. The MDS indicated Resident 26 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene.
During a review of Resident 23's Advanced directive acknowledgement form dated 3/8/2023 the signature and dated sections were blank.
During a concurrent interview and record review, on 10/16/2024, at 10:16 AM., with Resident 26, Resident 26's Advanced directive acknowledgement form, dated 9/21/2024 was reviewed. Resident 26 stated the facility did not discuss advanced directive information with him.
During an interview and record review on 10/16/2024, at 11:10 AM., with the SSD, the SSD stated the advanced directive acknowledgement form needs to have the residents' signature and date to be complete and accurate, the signature of the residents acknowledges receipt of the information given.
During an interview on 10/18/2024, at 5:20 PM., with the Director of Nursing (DON), the DON stated advanced directives ensure that the wishes of the resident are made known to the facility. The DON stated, lack of an advanced directive or advanced directive acknowledgement form can lead to the facility missing out on what the residents' wishes are ultimately provide care that is not according to the residents wishes.
During an interview on 10/18/2024, at 5:40 PM., with the Facility Administrator (FA), the FA stated advanced directives need to be completed by social services. The FA stated Advanced directives or advanced directive acknowledgment form lets the facility know the healthcare wishes of the resident and if not completed may lead to care that does not follow the residents wishes.
During a review of facility's undated policy and procedures titled Advanced Directive, indicated, it is the policy of the facility to promote a resident's right to accept or refuse medical or surgical treatment, and the right to formulate an advanced directive .upon admission, all residents and representatives are presented with written information about their rights to .formulate an advanced directive.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 164's) medical reco...
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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 eight sampled residents (Resident 164's) medical records had accurately documented assessment reflective of the resident's use of an anticoagulant (a substance that prevents or treats blood clots in the heart and blood vessels [tubes that carry blood throughout the body]).
This deficient practice resulted in Resident 164's medical records being inaccurate and missing vital information of services being rendered to the resident.
Findings:
During a review of Residents 164's admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including Major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), atrial fibrillation (Afib- an irregular heartbeat that occurs when the electrical signals in the hearts upper chambers fire rapidly and out of synch with the lower chambers), and dysphagia (difficulty swallowing safely).
During a review of Resident 164's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/4/2024, indicated Resident 164 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 164 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. The MDS further indicated Resident 164 had a diagnosis of Afib however, however, the MDS did not indicate Resident 164 was on anticoagulant.
During a review of Resident 164's physicians orders dated 10/1/2024, indicated, Apixaban (medication used to treat blood clots) 5miligrams (mg -unit of measure) by mouth two times a day for deep vein thrombosis (DVT -a condition that occurs when a clot forms in a large vein deep in the body) prophylaxis (preventative treatment against disease).
During a concurrent interview and record review, on 10/18/2024, at 3:46 P.M., with MDS nurse, Resident 164's physician orders dated 10/1/2024 and MDS dated [DATE] were reviewed. MDS nurse stated MDS assessment is a comprehensive assessment for the care provided to the residents. MDS stated Resident 164 had an order for Apixaban, but it was not documented in the MDS assessment. MDS nurse stated apixaban should have been documented in the MDS so that the MDS reflective of the care that is being provided to the resident, total care.
During an interview on 10/18/2024, at 5:20 P.M., with the Director of Nursing (DON), the DON stated MDS assessments need to be completed accurately and completely to determine the level of care the resident needs, coordinate care based on the assessment and ultimately help in formulating a plan of care that is resident specific.
During a review of facility's policy and procedures dated 9/2023 title Resident Assessment, indicated, A comprehensive assessment of every resident need is made at intervals designated by OBRA and PPS requirements .
1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments .
During a review of the Centers for Medicare and Medicaid Services (CMS- a federal agency that provides health coverage to millions of people) Resident Assessment Instrument (RAI) dated 10/2024, title High risk drug classes, indicated, check if an anticoagulant medication was taken by the resident at any time during the 7 day look back period (or since admission/entry or reentry if less than 7 days) .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0680
(Tag F0680)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 6 (CNA 6) was trained and had the appropriate qualifications to serve as a qualified thera...
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Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 6 (CNA 6) was trained and had the appropriate qualifications to serve as a qualified therapeutic recreation specialist or an activities professional to support the physical, mental, and psychosocial well-being of 57 of 57 residents in the facility.
This deficient practice had the potential to result in a decline in the physical, mental, and psychosocial well-being the 57 residents.
Findings:
During an observation and concurrent interview on 10/16/2024 at 11:35 AM., CNA 6 was observed seated in the facility communal dining area monitoring residents as the residents watched Television. During an interview CNA 6 stated CNA 6 was covering for the Activities Director (AD) who was on vacation starting 10/15/2024. CNA 6 stated it was CNA 6's first day covering for the AD and that CNA 6 was trained on resident activities. CNA 6 stated CNA 6 was handed a guide (name not provided) on which activities to conduct with the residents.
During an interview on 10/16/2024 at 11:38 AM., the Director of Staff Development (DSD), stated CNA 6 was covering activities for the AD who was currently on vacation. The DSD also stated CNA 6 had not received training on how to conduct any activities with/for the residents.
During an interview on 10/18/2024 at 4:59 PM., the Director of Nursing (DON) stated the AD was on vacation since 10/15/2024. The DON stated activities help to keep residents' minds active and from further decline. The DON stated CNA 6 had worked with the AD in the past (unable to provide dates). The DON stated the DON did not know where the activity logs were kept. The DON stated the (DON) searched for the activities but could not find them.
During a review of the facility's undated AD Job Description indicated, the AD, is responsible for planning, organizing, developing, and directing the overall operations of the Activities Department, responsible for directing and managing an on-going program of activities designed to meet in accordance with assessments, the interest, and the physical, mental, and psychosocial well-being of all Residents. Qualifications include:
Associate degree or two years of college level course experience required.
Must be a qualified therapeutic recreation specialist or an activities professional who is licensed by the appropriate state and is eligible for said certifications or
Must have a minimum of 2 yrs experience in a social or recreation program within the last 5 years .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to develop a care plan (a document outlining a detailed approach to care customized to an individual resident's need) with measu...
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Based on observation, interview, and record review, the facility failed to develop a care plan (a document outlining a detailed approach to care customized to an individual resident's need) with measurable goals and interventions to address care and treatment of a resident with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) for one of one sampled resident (Resident 58).
This deficient practice had the potential to negatively affect the delivery of services to Resident 58.
Finding:
A review of Resident 58's admission record indicated the facility admitted Resident 58 on 9/26/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities) with psychotic disturbance anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and cognitive communication deficit (a disorder that affects a person's ability to communicate).
A review of Resident 58's Physician Orders, dated 9/26/2024 indicated:
1.Risperidone (medication to treat psychotic disturbance anxiety) 2 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) by mouth at bedtime for psychosis manifested by visual hallucinations
2.Seroquel (medication used to treat psychosis) 25mg 3 tablets (for a total of 75mg) by mouth at bedtime for psychosis manifested by visual hallucinations
A review of Resident 58's History and Physical (H&P) dated 9/27/2024, indicated the resident was recently hospitalized prior to admission for acute or chronic functional decline, progressive neurologic decline due to concerns for catatonia ( a condition in which a person is awake but does not seem to respond to other people and their environment and is characterized by abnormal movements, behaviors and withdrawals). The H&P also indicated during the hospitalization Resident 58 was noted to be wandering around, was restless and had abnormal stiffness and posture. The H&P further indicated the resident had experienced a cognitive decline for the past 18 to 20 months, was having hallucinations since early 2024. The H&P further indicated Resident 58 could make needs known but could not make medical decisions due to cognitive deficits and dementia.
A review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/30/2024, indicated the resident was able to understand others and was able to make himself understood. The MDS also indicated the resident had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions). Resident 58 was dependent upon . The MDS also indicated the resident was diagnosed with dementia was receiving antipsychotic and antianxiety medication.
During an observation of Resident 58 on 10/15/2024 at 8:56 AM, at Resident 58's bedside, Resident 58 was observed in bed with the head of bed elevated. Resident 58 had a flat affect, was still with hands posed in the air and her answers to questions were limited to one word answers.
A review of Resident 58's nurses progress note, dated 10/15/2024, indicated the resident was seen by the attending physician and the resident's order for Ativan (medication to relieve anxiety) was decreased from 1 milligram (mg-Unit of measurement) to 0.5mg at bedtime.
A review of Resident 58's Physician Orders, dated 10/16/2024 indicated to administer Ativan 0.5 mg every 12 hours until 10/20/2024 and at bedtime for catatonia manifested by rigidity.
A review of Resident 58's Care Plans on 10/17/2024 at 9:00AM, indicated there was no individualized person-centered care plan for the resident's dementia care which included measurable objectives, monitoring, and a timetable to meet resident's needs.
A review of Resident 58's September and October 2024 Medication Administration Records ((MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) indicated the resident received the following:
1.eight doses of Ativan 0.5 mg from 9/27/2024 to 10/18/2024 and
2.five doses of Ativan 1mg from 9/27/2024 to 10/18/2024
3.18 doses of Seroquel 200 mg from 9/27/2024 - 10/18/2024
4.18 doses of Risperidone 75 mg from 9/27/2024 - 10/18/2024
During a concurrent interview and record review on 10/17/2024 at 10:10 AM, Resident 58's electronic medical chart was reviewed with Registered Nurse Supervisor (RNS) 2. RNS 2 stated Resident 58 has diagnoses of anxiety disorder and dementia. RNS 2 further stated Resident 58 did not have any care plan with measurable goals and interventions that addressed the resident's diagnosis of dementia or cognitive skills. RNS 2 was unable to provide documented evidence the licensed nursing staff identified and/or assessed specific behaviors or episodes .
During an interview on 10/18/2024 at 3:41 PM, the Director of Nursing (DON) stated Resident 58 should have a dementia care plan in order to address the care the resident receives. The DON stated the care plan would include the behavioral interventions one would implement in caring for a resident with dementia. A possible outcome of not having a dementia care would be the resident would not receive the care needed.
During a review of the facility's policy and procedures (P&P) titled Management of Dementia, undated, the P&P indicated it was the facility's policy that residents with indications of dementia receive appropriate interventions or treatment based on clinical symptoms. The P&P further indicated For the individual with confirmed dementia, the staff and physician will identify a plan to maximize remaining function and quality of life.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the failed to obtain a physician's order and clinical indication to apply me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the failed to obtain a physician's order and clinical indication to apply medication for one of 13 sample residents (Resident 53).
This deficient practice resulted in Resident 53 applying the antifungal powder under the breasts without a physician's order and clinical indication for the antifungal powder.
Cross Reference F554
Findings:
During a review of the admission record indicated Resident 53, was admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia (a serious medical condition that occurs when the lungs have trouble loading the blood with enough oxygen and body tissues), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), major depressive disorder (a mental health condition that involves persistent feelings of sadness, hopelessness, and a loss of interest in activities), and muscle weakness and dysphagia (medical term for swallowing difficulties).
During a review of Resident 53's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 09/21/2024, indicated Resident 5's cognition (The mental ability to make decision of daily living) was intact. The MDS indicated Resident 53 was independent with eating, oral hygiene, and required partial moderate assistance with upper body dressing, was dependent for Toileting hygiene, shower/bathe, lower body dressing, required limited assistance with his activities of daily living.
During a concurrent observation and interview on 10/15/2024, at 7:56 AM, Resident 53's bedside drawer was observed with unlabeled medication dispensing cup and a white powder like substance inside the medication dispensing cup. Resident 53 was asked if she knew what the white powder that was inside the unlabeled medication cup. Resident 53 stated, it is antifungal (medication to treat fungal infection/s) powder and that she applies the powder under her breast.
During an interview on 10/15/2024, at 7:56 AM., Certified Nursing Assistant 5 (CNA5) stated CNA 5 did not know what was in the medicine cup. CNA5 further stated, it looks like a powder the white powdered substance.
During an interview on 10/15/2024 at 8 AM., with the Treatment Nurse 1 (TXN 1), TXN 1 stated TXN 1 did not know what the white powdered substance in the medication dispensing cup on top of Resident 53's bedside drawer was. TXN 1 further stated, the powder in the medication cup is not supposed to be on top of resident's bedside drawer, because it is not labeled and thus unidentifiable. TXN 1 also stated leaving an unlabeled medication cup with an unidentifiable powder in places the Resident at risk of ingesting a white powder that may be unsafe for consumption and if consumed could cause an allergic reaction that could result in anaphylaxis and even death.
During an interview on 10/18/2024 at 4:53 PM., with the Director of Nursing (DON), the DON stated, Residents are only allowed for have medications at bedside if they have been assessed to be cognitively intact and have physically demonstrated that they can safely be able to do so and have a physician approval. The DON stated without resident assessment, the medication may be applied/administered incorrectly, placing the resident at risk for skin breakdown, irritation, and or redness. The DON also stated medication at bedside should be secured in a locked container.
During a review of the Physician Orders dated 10/18/2024, indicated no order to apply antifungal powder under Resident 53's breasts.
During a review of Resident 53's Medication Administration Record (MAR) for 10/2024, indicated no order to apply antifungal powder under Resident 53's breasts.
During a review of the facility's policy and procedures titled Self-Administration of Medication dated 09/2023 indicated, .the IDT, assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the Resident. Policy further states self-administered medications are stored in a safe and secure place, which is not accessible by other Residents .
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** a. During a review of Resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** a. During a review of Resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), major depressive disorder (A mental health condition that involves persistent feelings of sadness, hopelessness, and a loss of interest in activities), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs) and, neoplasm (cancer) of the prostate (a gland in the male reproductive system).
During a review of Resident 4's MDS, dated [DATE], indicated Resident 4's mental cognition was moderately impaired. The MDS indicated Resident 4 required partial moderate assistance for eating and oral hygiene and upper body dressing, was dependent for toileting hygiene, shower/bathing self, and lower body dressing.
During a review of Resident 4's care plan titled, The Resident has Limited Physical Mobility Related to Feeding (R/T) and Needs Assistance with Feeding, initiated on 9/23/2024, indicated Resident 4 had limited physical mobility related to feeding and needs assistance with feeding.
During a meal observation on 10/15/2024 at 8:31AM, CNA 5 was observed feeding Resident 4 inside the residents' room. CNA 5 was standing to the right side of Resident 4 while feeding the resident.
During an interview on 10/15/2024 at 8:37 AM, CNA 5 stated CNA 5 is supposed to beside the patient while assisting the resident with feeding.
During an interview on 10/15/2024 at 12:51 PM with Director of Staff Development (DSD), DSD stated, CNAs are supposed to be seated, have eye level contact with the resident when assisting the resident with feeding.
During an interview on 10/18/2024 at 4:43 PM with Director of Nursing (DON), DON stated, CNAs should sit on a chair at eye level on the side that is easy for the resident to eat, ensure the resident is not looking up at the staff and is eating at a comfortable pace for the resident dignity. DON further stated assisting a resident with feeding while standing up diminishes the resident's dignity.
During a review of the facility's policy and procedures (P&P) titled, Dignity, revised 11/2023, 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. Residents provided with a dignified dining experience.
Based on observation, interview, and record review, the facility failed to ensure staff provided dignified dining experience while assisting two of 15 sampled residents (Residents 4 and 58) during meals; by ensuring Residents 4 and 58 were fed at eye level to maintain face-to-face contact with the residents.
This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Resident 4 and Resident 58).
b. During a review of Resident 58's admission record indicated the facility admitted the resident on 9/26/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing) and muscle weakness (a lack of strength in the muscles).
During a review of Resident 58's Skilled Nursing Facility admission History and Physical (H&P), dated 9/27/2024, indicated Resident 58 was recently hospitalized for acute (of sunset onset) or chronic (on going) functional decline, progressive neurologic (relating to the nervous system or nerves) declined, and had experienced a cognitive (the mental ability to make decisions) decline for the past 18 to 20 months. The H&P also indicated Resident 58 could make needs known but could not make medical decisions due to cognitive deficits and dementia (a progressive state of decline in mental abilities).
During a review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/30/2024, indicated the resident was able to understand others and was able to make himself understood. The MDS also indicated the resident had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions). Resident 58 was dependent upon staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 58 was diagnosed with dementia was receiving antipsychotic and antianxiety medication.
During a review of Resident 58's Order Summary Report, dated 10/18/2024, indicated a physician's order for a certified nursing assistant (CNA) to assist in feeding Resident 58.
During a review of Resident 58's nutritional problem care plan developed on 10/2/2024, indicated the Resident 58's nutritional problem was due to the resident's chewing difficulties. The care plan interventions included for staff to provide and serve diet as ordered and for staff to monitor and record intake of every meal for Resident 58.
During an observation on 10/15/2024 at 12:39 PM, Certified Nursing Assistant 1 (CNA 1) was observed on the right side of Resident 58's bed standing over feeding Resident 58.
During a concurrent observation and interview on 10/15/2024 at 12:45 PM in Resident 58's room, CNA 1 was observed standing over Resident 58 while feeding the resident. CNA 1 stated CNA 1 should not stand over Resident 58 while feeding the resident to maintain the resident's dignity.
During an interview on 10/18/2024 at 3:45 PM, with the Director of Nursing (DON), the DON stated staff should be sitting and at eye level with the resident when feeding the residents. The DON stated, Staff should feed residents at eye level and not stand over the residents while feeding the residents. The DON further stated, we feed the residents at eye level with the resident when feeding to show dignity for the resident.
During a review of the facility's policy and procedures (P&P) titled, Dignity, revised 11/2023, 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. Residents provided with a dignified dining experience.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide on-going activities, based on comprehensive assessment and resident's preferences, that meets the interests and to su...
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Based on observation, interview, and record review, the facility failed to provide on-going activities, based on comprehensive assessment and resident's preferences, that meets the interests and to support the physical, mental, and psychosocial well-being of 57 of 57 facility Residents.
This deficient practice had the potential to result in lack of feelings of well-being and meaningfulness for the resident.
Cross Reference F680
Findings:
During an observation and concurrent interview on 10/16/2024 at 11:35 a.m. Certified Nursing Assistant 6 (CNA 6) was observed seated in the facility communal dining area monitoring residents as the residents watched Television. During an interview CNA 6 stated CNA 6 was covering for the Activities Director (AD) who was on vacation starting 10/15/2024. CNA 6 stated it was CNA 6's first day covering for the AD and that CNA 6 was trained on resident activities. CNA 6 stated CNA 6 was handed a guide (name not provided) on which activities to conduct with the residents.
During an interview on 10/16/2024 at 11:38 a.m., the Director of Staff Development (DSD), stated CNA 6 was covering activities for the AD who was currently on vacation. The DSD also stated CNA 6 had not received training on how to conduct any activities with/for the residents.
During an interview on 10/18/2024 at 4:59 p.m., the Director of Nursing (DON) stated the AD was on vacation since 10/15/2024. The DON stated activities help to keep residents' minds active and from further decline. The DON stated CNA 6 had worked with the AD in the past (unable to provide dates). The DON stated the DON did not know where the activity logs were kept. The DON stated the (DON) searched for the activities but could not find them.
During a review of the facility's undated AD Job Description indicated, the AD, is responsible for planning, organizing, developing, and directing the overall operations of the Activities Department, responsible for directing and managing an on-going program of activities designed to meet in accordance with assessments, the interest, and the physical, mental, and psychosocial well-being of all Residents. Qualifications include:
Associate degree or two years of college level course experience required.
Must be a qualified therapeutic recreation specialist or an activities professional who is licensed by the appropriate state and is eligible for said certifications or
Must have a minimum of 2 yrs experience in a social or recreation program within the last 5 years .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Residents 164's admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses includi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Residents 164's admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including Major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), atrial fibrillation (Afib- an irregular heartbeat that occurs when the electrical signals in the hearts upper chambers fire rapidly and out of synch with the lower chambers), and dysphagia (difficulty swallowing safely).
A review of Resident 164's MDS dated [DATE], indicated Resident 164 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 164 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. MDS further indicated Resident 164 had a diagnosis of Afib however, there MDS did not indicate that Resident 164 was on an anticoagulant.
A review of Resident 164's Physicians Orders dated 10/1/2024, indicated, Apixaban (used to treat health problems caused by a blood clot) 5miligrams (md -unit of measure) by mouth two times a day for deep vein thrombosis (DVT -a condition that occurs when a clot forms in a large vein deep in the body) prophylaxis (preventative treatment against disease).
A review of Resident 164's MAR for 10/2024, indicated Resident 164 received a total of 32 doses of Apixaban 5mg from 10/1/2024 to 10/18/2024.
During a concurrent interview and record review, on 10/18/2024, at 11:34 AM., with Registered Nurse Supervisor 1 (RNS 1), Resident 164's chart was reviewed. RNS 1 stated there was no care plan for activates and there was no care plan for apixaban. RNS 1 stated residents need to have care plan so the facility can provide overall and individualized care to the residents.
During an interview on 10/18/2024, at 5:20 PM., with the Director of Nursing (DON), the DON stated residents need to have care plans to ensure that the resident is receiving appropriate care. The DON stated, if residents do not have a care plan, resident is not receiving patient centered care.
During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2023, indicated, The comprehensive, person-centered care plan:
a. includes measurable objectives and timeframes.
b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
Based on interview, and record review, the facility failed to create a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) to meet the needs of two of five sampled residents (Residents 58 and 164) by failing to:
-Develop a care plan for Resident 58's psychotropic (a medication that affects behavior, mood, thoughts, or perception) medications and their targeted behavior of visual hallucinations for Resident 58.
- Develop a care plan for Resident 164's activities and anticoagulant (medication used to prevent blood clots) medication.
These deficient practices placed Residents 58 and 164 at increased risk for suboptimal care from facility staff in these care areas leading to diminished physical, mental, and psychosocial well-being.
Findings:
a. During a review of Resident 58's admission Record indicated an the facility admitted the resident on 9/26/2024 with diagnoses of dementia (a progressive state of decline in mental abilities) with psychotic disturbance (severe mental disorder that causes a person to lose touch with reality), anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and cognitive communication deficit (a disorder that affects a person's ability to communicate).
During a review of Resident 58's Physician Orders, dated 9/26/2024, indicated the facility to administer the following medications to Resident 58:
- Risperidone (an antipsychotic medication) 2 milligrams (mg- unit of measurement) by mouth at bedtime for psychosis manifested by visual hallucinations (involves seeing things that aren't real)
- Seroquel (an antipsychotic medication) 25mg - give 3 tablets (for a total of 75mg) by mouth at bedtime for psychosis manifested by visual hallucinations.
During a review of Resident 58's Skilled Nursing Facility admission History and Physical (H&P), dated 9/27/2024, indicated Resident 58 was recently hospitalized for progressive neurologic decline and has experienced a cognitive decline for the past 18 to 20 months. The H&P also indicated Resident 58 could make needs known but could not make medical decisions due to cognitive deficits and dementia.
During a review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/30/2024, indicated the resident was able to understand others and was able to make herself understood. The MDS also indicated the resident had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions) and the resident was dependent upon staff for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated the resident was diagnosed with dementia was receiving antipsychotic and antianxiety medication.
During a review of Resident 58's Medication Administration Records (MAR) for 9/2024 and 10/2024, the MARs indicated Resident 58 received the following:
- 18 doses of Seroquel 200 mg from 9/27/2024 to 10/18/2024
- 18 doses of Risperidone 75 mg from 9/27/2024 to 10/18/2024
During a review of Resident 58's Care Plans on 10/17/2024 at 9 AM, indicated there were no individualized person-centered care plans with measurable objectives, monitoring, and a timetable to meet the needs that addressed the resident's use of Seroquel and Risperidone or for the behavior of visual hallucinations.
During a concurrent interview and record review on 10/17/2024 at 10:20 AM, Resident 58's care plans and physician orders for Seroquel, and Risperidone were reviewed with Registered Nurse Supervisor 2 (RNS 2). RNS 2 stated Resident 58 was currently taking/receiving Seroquel and Risperidone. RNS 2 also stated Resident 58 did not have care plans that addressed Resident 58's indications for Seroquel or Risperidone. RNS 2 stated a care plan should be developed for any psychotropic medication. RNS 2 further stated we have to care plan the behaviors and side effects of the medication and it was possible for Resident 58 to have side effects or for the resident's behavior to go untreated if the medications were not care planned.
During an interview on 10/18/2024 at 8:19 AM, MDS 1 stated Resident 58 should have care plans in place that address the use of antipsychotic medication. MDS 1 stated, it is important to care plan the manifestation, behaviors so that the particular symptom(s) can be treated effectively.
During an interview on 10/18/2024 at 3:42PM, the Director of Nursing (DON) stated all psychotropic medications and the behaviors being treated by the psychotropics, should be care planned for. The DON stated potential outcome of not initiating a care plan is the lack of care and inability to deliver necessary interventions and monitoring for a resident.
During a review of the facility's policy and procedures (P&P) titled, Antipsychotic Medication Use, revised 3/2023, the staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications.
During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2023, indicated, The comprehensive, person-centered care plan:
a. includes measurable objectives and timeframes.
b. 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 F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Residents 164's admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses includi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Residents 164's admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), Afib., and dysphagia (difficulty swallowing safely).
A review of Resident 164's MDS dated [DATE], indicated Resident 164 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The same MDS indicated Resident 164 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. The same MDS further indicated Resident 164 had a diagnosis of Afib however, there MDS did not indicate that Resident 164 was on an anticoagulant.
A review of Resident 164's physicians orders dated 10/1/2024, indicated: Apixaban (used to treat health problems caused by a blood clot) 5mg by mouth two times a day for deep vein thrombosis (DVT -a condition that occurs when a clot forms in a large vein deep in the body) prophylaxis (preventative treatment against disease), mirtazapine 30mg one tablet by mouth at bedtime for depression manifested by poor by mouth intake and escitalopram 5mg one tablet by mouth one time a day for depression manifested by poor by mouth intake.
A review of Resident 164's care plan dated 10/2/2024, indicated Medication: Escitalopram, Mirtazapine . Interventions; assess/record effectiveness of drug treatment, monitor and report signs and symptoms of sedation .
During a concurrent interview and record review, on 10/18/2024, at 11:50 A.M., with Registered Nurse Supervisor (RNS) 1, Resident 164's physician orders dated 10/1/2024, care plans and MAR for 10/2024 were reviewed. RNS 1 stated, apixaban is an anticoagulant that requires facility to monitor residents of any signs and symptoms of bleeding, finding or lack thereof need to be documented on the MAR every shift. RNS 1 stated monitoring for signs and symptoms of bleeding is part of the facility protocol batch that needs to be ordered automatically by the nursing staff whenever there is an order for anticoagulant for a resident. RNS 1 stated Resident 164 did not have an order to monitor for signs and symptoms of bleeding and therefore there was no monitoring for the apixaban on the MAR that was only be triggered once the order to monitor for bleeding was entered in the orders. RNS 1 states not monitoring for bleeding may lead to possibility of resident bleeding and alter the overall wellbeing of the resident. RNS 1 stated needs to monitor antidepressants so that the facility may not miss any behaviors and their frequency which can ultimately give guidance as to when a medication needs to be discontinued or adjusted. Not monitoring the side effects of the medication can lead to residents' care not being met.
During an interview on 10/18/2024, at 5:20 P.M., the DON stated the facility needs to monitor residents that are on anticoagulants and antidepressants, documents the findings on the MAR. The DON stated lack of monitoring and documenting findings for residents on anticoagulants may lead to bleeding that may go unnoticed and possible anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy oxygen carrying blood cells) and hospitalization. The DON further stated resident on antidepressants need to be monitored for behaviors and side effects which need to be documented on the MAR. If there is no monitoring for antidepressants, side effects and behaviors may not be captured, and dosing may not be adjusted appropriately.
A review of the facility's P&P titled, Antipsychotic Medication Use, reviewed 3/2023, the P&P indicated The staff will observe, document, and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician.
Based on interview and record review, the facility failed to provide appropriate monitoring of anticoagulants (blood thinner; a substance that hinders the clotting of blood) and antidepressants (medication used to treat depression [mental health that involves persistent feeling of sadness, loss of interest and low mood that lasts for a long time] for two of ten sampled residents (Resident 6 and Resident 164).
These deficient practices had the potential to result in complications from the use of antidepressants and anticoagulants such as bruising, bleeding to Resident 6 and Resident 164.
Findings:
1.A review of Resident 6's admission Record indicated the facility originally admitted the resident on 2/13/2020 and re-admitted the resident on 11/1/2023 with diagnoses including atrial fibrillation (AFib - an irregular often rapid heart rate that commonly causes blood clots), transient ischemic attack and cerebral infarction (damage to brain tissues caused by lack of oxygen to the area).
A review of the physician order, dated 2/8/2023, indicated staff were to monitor Resident 6 for signs and symptoms of bleeding including prolonged bleeding in the nose, eyes, gums, bruises that don't heal, blood in the urine and black tarry stool. The physician order further indicated staff were to notify the physician if there was bleeding every shift due to use of Eliquis.
A review of the Physician's Order, dated 4/4/2023, indicated Resident 6 was to receive Eliquis (medication used to prevent blood clots)
5 milligrams (mg, unit of measurement) by mouth two times a day with breakfast and dinner for AFib.
A review of the care plan titled, potential for bleeding, bruising and/or skin discolorations, developed 11/2/2023 indicated Resident 6 was at risk due to the use of anticoagulant therapy secondary to diagnosis of a-fib. A review of the care plan indicated the goals was for the resident to have no episodes of bleeding. The care plan interventions included:
1.To monitor for bruising or bleeding every shift
2.To monitor for blood in the urine or stool
3. Notify the physician of signs of bleeding and
4. To use a soft toothbrush for brushing and watch for any gum bleeding.
A review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/7/2024, indicated the resident's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were moderately impaired. The MDS also indicated Resident 6 required partial assistance to set up assistance with dressing, eating and toileting hygiene and bathing. The MDS further indicated the resident was taking an anticoagulant.
During a record review on 10/18/2024 at 7:25 AM, the October 2024 medication administration records ((MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), Resident 6 received Eliquis twice a day. A review of the MAR also indicated no documented evidence the licensed nurses monitored for side effects of Eliquis.
During a concurrent interview and record review on 10/18/2024 at 8:13 AM, Resident 6's electronic chart physician orders and MAR were reviewed with the MDS Nurse. MDS Nurse stated Resident 6 was currently taking Eliquis. The MDS Nurse stated there was no order for the monitoring for side effects or bleeding related to the use of Eliquis. MDS stated Resident 6 previously had an order, but it was not carried over when she was re-admitted in November 2023. The MDS Nurse stated staff should monitor for bleeding and there was a high risk for bruising.
During an interview on 10/18/2024 at 3:43 PM, the Director of Nursing (DON) stated it is the facility's practice to monitor for bleeding and bruising for those residents' taking anticoagulants. The DON stated the nursing staff should have monitored Resident 6's for bleeding and bruising and document it on the MAR. The DON stated a potential outcome of not monitoring for the side effects of Eliquis was Resident 6 could have an episode of sudden bleeding.
According to the Nurse's Drug Handbook, 2022, Eliquis side effects included bleeding and excessive bleeding leading to hemorrhage. The Nursing Drug Handbook indicated to monitor closely for bleeding as Eliquis may cause life-threatening bleeding.
During a review of the facility's policy and procedures (P&P) titled, Anticoagulation- Clinical Protocol, reviewed 4/2024, the P&P indicated the staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems.
a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Residents 164's admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses includi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Residents 164's admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including Major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), atrial fibrillation (Afib- an irregular heartbeat that occurs when the electrical signals in the hearts upper chambers fire rapidly and out of synch with the lower chambers), and dysphagia (difficulty swallowing safely).
A review of Resident 164's MDS dated [DATE], indicated Resident 164 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The same MDS indicated Resident 164 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene.
A review of Resident 164's physicians orders dated 10/1/2024, indicated:
Mirtazapine (medication to treat depression) 30mg one tablet by mouth at bedtime for depression manifested by poor by mouth intake and Escitalopram 5mg one tablet by mouth one time a day for depression manifested by poor by mouth intake.
During a concurrent interview and record review, on 10/18/2024, at 11:34 A.M., with RNS 1, Resident 164's Facility Verification of Informed Consent to Physical Restraints Psychotherapeutic Drug or prolonged use of Active Device Form (Verification of Informed Consent) dated 10/1/2024 was reviewed. RNS 1 stated informed consent needs to be accurately completed reflecting the dose, route, frequency of the medication and each medication needs not have its own informed consent. RNS 1 stated not filling out the consent form accurately may lead to medication errors.
During a concurrent interview and record review, on 10/18/2024, at 5:20 P.M., with DON, Resident 164's Facility Verification of Informed Consent to Physical Restraints Psychotherapeutic Drug or prolonged use of Active Device Form (Verification of Informed Consent) dated 10/1/2024 was reviewed. The DON stated consent forms for antipsychotics should not have two medications on one form, each medication needs to have its own consent form that also includes the dose, diagnosis, and behaviors to be treated. DON states inaccurate informed consents forms may lead to resident not knowing that they are taking the medication. DON stated residents needs to be able to have the choice or right to make the decision to take the medication and the dose being prescribed.
During a review of the facility's policy and procedures (P&P) titled Informed Consent - Psychotherapeutic Medications and Restraint Devices revised 12/14/2023, the P&P indicated the healthcare practitioner ordering psychotherapeutic medication is responsible for Providing documentation that informed consent was obtained, including the diagnosis/clinical indications for the medication, Ordering psychotherapeutic (chemical) restraint medication and obtaining informed consent for the dosage range/specific dosage for each consent and obtaining informed consent from the resident/surrogate decision maker Prior to receipt of the medication when a psychotherapeutic medication is ordered throughout the resident's stay in the facility.
Based on observation, interview, and record review, the facility failed to ensure the facility document titled, Facility Verification of Informed Consent, (a principle in medical ethics, medical law, and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) form was fully completed and properly executed for psychotropic (medications that affect the mind, emotions, and behavior) medication for two of five sampled residents (Residents 58 and 164).
This deficient practice had the potential for Residents 58 and 164 not to be fully informed of the risk and benefits of the psychotropic medication they were receiving.
Findings:
a. A review of Resident 58's admission record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) with psychotic disturbance anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and cognitive communication deficit (a disorder that affects a person's ability to communicate).
During a review of Resident 58's Physician Orders (PO), dated 9/26/2024 , the PO indicated: risperidone (medication used to treats psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] 2 milligrams (mg, unit of measurement) by mouth at bedtime for psychosis manifested by visual hallucinations; Seroquel (medication to treat psychosis) 25mg 3 tablets (for a total of 75mg) by mouth at bedtime for psychosis manifested by visual hallucinations
During a review of Resident 58's History and Physical (H&P), dated 9/27/2024, the H&P indicated Resident 58 was recently hospitalized for acute or chronic functional decline, progressive neurologic declined and has experienced a cognitive decline for the past 18 to 20 months. The H&P also indicated Resident 58 could make needs known but could not make medical decisions due to cognitive deficits and dementia.
A review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/30/2024, indicated Resident 58 was able to understand others and was able to make himself understood. The MDS further indicated the resident had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions). Resident 58 was dependent upon. The same MDS indicated the Resident 58 was diagnosed with dementia was receiving antipsychotic and antianxiety medication.
A review of Resident 58's Physician Orders dated 10/16/2024 indicated Ativan (an anti-anxiety medication) 0.5 mg every 12 hours until 10/20/2024 and at bedtime for catatonia (a condition in which a person is awake but does not seem to respond to other people and their environment and is characterized by abnormal movements, behaviors, and withdrawals) manifested by rigidity.
A review of Resident 58's September and October 2024 Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) indicated the resident received the following:
1. eight doses of Ativan 0.5 mg from 9/27/2024 to 10/18/2024 and
2. five doses of Ativan 1mg from 9/27/2024 to 10/18/2024
3. 18 doses of Seroquel 200 mg from 9/27/2024-10/18/2024
4. 18 doses of Risperidone 75 mg from 9/27/2024-10/18/2024
A review of Resident 58's anti-anxiety medication care plan, developed 10/16/2024, indicated Resident 58 was receiving Ativan for anxiety manifested by catatonia syndrome. The care plan interventions included to document and notify physician if mood state interferes with functioning, develop a meaningful activity for the resident while in the facility to divert attention.
During a concurrent interview and record review of Resident 58's active chart on 10/17/2024 at 10:50 AM, a Facility Verification of Informed Consent to Physical Restraints Psychotherapeutic Drug or prolonged use of Active Device Form (Verification of Informed Consent) for Ativan, Risperidone, and Seroquel was reviewed with Registered Nurse Supervisor (RNS) 2. RNS 2 stated all three medications were listed out on the one Verification of Informed Consent Form. RNS 2 confirmed and stated the form was not completed correctly. RNS 2 stated each medication should have its own form and the dosage and frequency should also be written on the form. RNS 2 stated psychotropic medications are high risk medications and the Verification of Informed Consent Form's is used to inform the resident and or family of the medications side effects and risks.
During an interview on 10/18/2024 at 4:37 PM, the Director of Nursing (DON) stated Resident 58's form was completed incorrectly. The DON stated each medication should have its own individual form. The DON further stated the medication's dosage, frequency and diagnosis should be written out on an individual form. The DON stated the purpose of obtaining informed consent before administering psychotropic medication was to ensure the resident is aware of the risks and benefits of the medication and so the resident can be monitored for any effects of taking the medication. The DON further stated an incorrectly executed Informed consent could lead to the resident being unaware of the medication or dosage they were taking.
CONCERN
(E)
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 provide a homelike environment by failing to ensure 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 a homelike environment by failing to ensure a pest free environment for one of six sampled residents (Resident 214).
This deficient practice resulted in Resident 214 being bitten by ants and a potential of a facility wide infestation of ants and other residents being affected by a wider infestation.
Findings:
A review of Resident 214's admission Record indicated Resident 214 was admitted to the facility on [DATE], with diagnoses that included, anxiety disorder, (restlessness, worried, tense, or afraid of what may happen in the future), muscle weakness (a lack of physical or muscle strength, throughout the body).
A review of Resident 214's Minimum Data Set (MDS - a federally mandated resident assessment tool), indicates Resident 214's cognition (the mental ability to make decisions of daily living) was intact, and can make decisions for medical care and perform all activities of daily living.
During a concurrent observation and interview on 10/15/24 at 10:43 AM Resident 214 stated there were ants on the wall and at the bottom of the door that leads outside to the rear of the facility from Resident 214's room. During an observation it was noted that ants were crawling on the side of the wall just inside the sliding glass door that leads outside the resident's room to the back walkway of the facility. It was observed that ants were also crawling on the floor just inside the sliding glass door that leads to the back walkway of the facility.
During an observation and a concurrent interview on 10/15/24 at 10:55 AM, the Maintenance Supervisor (MS) stated just yesterday, the facility had fumigation services for ants and pests to the outside and inside of the facility. The MS confirmed there were ants in Resident's 214's room. The MS stated that he would do a room to room check of the facility to ensure a homelike environment free of pests.
During a review of the facility document titled, Total Maintenance Service Invoice #:14025, dated 10/14/2024 at 9:05 am, the document indicated the following: Performed exterior treatment around facility for heavy ant activity. 4 colonies found in trees by sidewalk. All colonies were treated, please give 72 hours for chemical to fully take effect. Also, interior unites 1, 14, staff lounge, doctors office/lounges, dining, and nurse stations were all bated for ants. Also, interior kitchen was serviced, and no roaches found. Rodent devices have been checked and no mice captured or signs of pest. Fly, light has also been serviced and glue boards replaced.
During an interview on 10/16/24 at 2:13 PM, the MS stated he had to spray the ants inside the resident's room himself since the Fumigation company would take at least 24 hours to return.
During an interview on 10/18/24 at 2:24 PM, the Director of Nursing (DON) stated fumigation services was called a few days ago for ants reported outside the building. Fumigation company has already sprayed for bugs on the perimeter of the facility. There was no spaying for insects inside the building only on the outside of the facility. Because ants have been discovered inside the facility the staff will do a room to room check for insects and then, if necessary, we will call the fumigation company to come out to spray inside the facility. The DON stated that residents should be able to live in a pest free environment and it was the responsibility of the facility to ensure their rooms and living areas are always pest free.
During a review of the facility's policy and procedures (P&P) titled, Homelike Environment revised 9/2023, 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 .Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure safe food storage practices in the kitchen for by failing to ensure expired canned food, corned beef hash 6-pound (lbs...
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Based on observation, interview, and record review, the facility failed to ensure safe food storage practices in the kitchen for by failing to ensure expired canned food, corned beef hash 6-pound (lbs., unit of measurement) 12 ounce (oz, is a unit of measurement) was not stored in the same location as non-expired food to be served to residents in the food storage area along with all other canned foods not expired. The corned beef hash was expired on 10/2022.
This deficient practice had the potential to result in harmful bacteria growth and the consumption of spoiled food that could lead to foodborne illness (caused by contamination of food and occur at any stage of the food production, delivery, and consumption chain) in 57 of 57 residents who received food from the kitchen.
Findings:
During an interview and a concurrent observation of the walk-in food storage area on 10/15/2024 at 7:10 AM, the Dietary Supervisor (DS) confirmed the findings and stated expired canned food should be separated from the non-expired food. Some dented cans were also observed. The DS stated the observed expired food should have been separated to ensure that residents are not served expired food. The DS stated that expired food should not be served to the residents because they are elderly and have medical conditions and eating expired food could make them sick and cause digestive issues.
During a review of the facility's policy and procedures (P&P) titled Damaged Cans and Packages to be Returned to Vendor, dated 1/1/2017 and revised on 1/1/2018, the P&P indicated under Regulation/Surveyor Guidance- Store, prepare, distribute and serve food in accordance with professional standards for food service safety.Procedure: 1. All foods delivered require inspection 4.Place all damaged goods in specified area labeled Return to Vendor Do Not use . The location of this area is in the storeroom .6. Discard if vendor doesn't want to see product.
During a review of the facility's P&P titled Storage of Food and Supplies, dated 2017 and 2018, the P&P indicated Policy: Food and supplies will be stored properly and in safe manner .Procedures for Dry Storage: 8. Food stored should be arranged in food groups to facilitate storing, locating and taking inventories. Similar items such as cereals or fruits should be grouped and alphabetized withing group. (Have a separate area labeled for dented cans and damaged food items.) Labels should be visible, and the arrangement should permit rotation of supplies so that oldest items will be used first. All food will be dated - month, day, year. All food products will be used per the times specified in the .Dry Food Storage Guidelines, in this Policy and Procedure Book. The storage times in the guidelines are intended to be on the safe side .Exception: If you have product information about specific items, (ie., spices, condiments, baking mixes) allowing a longer shelf life than the one in the Dry Food Storage Guidelines, you can use that storage time instead. Keep that documentation on hand in case you are asked for it. No food will be kept longer than the expiration date on the product.
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
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 document an accurate fall risk assessment (an evaluation to determin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document an accurate fall risk assessment (an evaluation to determine a resident's risk for fall based on different variables) for one of three sampled residents, (Resident 1).
This deficient practice had the potential to place Resident 1 at risk for fall(s) causing injuries or even death.
Findings:
A review of Resident 1's admission Record indicated the facility admitted this [AGE] year old female on 2/15/2024 with diagnoses including Osteoporosis (brittle bones) with current pathological fracture (broken bone), Atherosclerotic heart disease (thickening or hardening of the vessels that return blood back to the heart), Chronic Kidney Disease stage 4 (very decreased functioning of the kidney's ability to filter), Sick Sinus Syndrome (type of heart dysrhythmia), presence of cardiac pacemaker, Hyperlipidemia (high cholesterol), Essential Tremor (neurological condition that causes your hands to shake rhythmically), hearing loss left ear, history of Malignant neoplasms (cancer) of breast, large intestine and skin, history of falling.
A review of Resident 1's History and Physical (H&P: the physician's examination and plan of care of the patient) dated 2/15/2024 indicated Resident 1 was admitted to the facility after a fall that resulted in a T 10 hyperextension fracture (spinal fracture) that required no intervention.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/21/2024 indicated Resident 1's cognition (the mental ability to make decisions of daily living)was moderately impaired. Resident 1 required an assistive device (walker) and moderate assistance (helper does more than half the effort) with ambulation (walking) and toileting.
During a concurrent interview and record review on 4/17/2024 at 10:06 a.m. with the licensed vocational nurse (LVN), Resident 1's Fall Risk assessment dated [DATE] was reviewed. Resident 1's Fall Risk Assessment indicated Resident 1 had no falls in the past three months; Resident 1 was at low risk for fall. The LVN stated, When I completed this assessment, I did not look at her H&P that indicated she had a fall prior to admission. Each section of the assessment is assigned points and you tally the points to determine if the resident is at low, medium, or high risk for fall. If I would have looked at her H&P that may have changed her score and identified her as a risk for fall.
During an interview on 4//17/2024 at 10:43 a.m. the Director of Nursing (DON) stated, Fall risk assessments should be completed at admission, after a fall incident and quarterly. The information used to complete the assessment should include all facility documentation as well as the history and physical from the physician to determine if the resident has a history of falls .
A review of the facility's policy and procedures titled, Falls Clinical Protocol revised 3/2022 indicated: Assessment and Recognition:
1.Nursing staff and IDT will identify individuals with a history of falls and risk factors for falling.
a. Staff will ask the resident and the caregiver or family about a history of falling.
b. The staff and physician will document in the medical record a history of one or more recent falls.
2. In addition, the nurse shall assess and document/report the following:
a. Vital signs;
b. Recent injury, especia11y fracture or head injury.
c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.;
d. Change in cognition or level of consciousness.
e. Neurological status;
f. Pain;
g. Frequency and number of falls since last physician visit;
h. All current medications, especially those associated with dizziness or lethargy; and
i. All active diagnoses.
3. Staff will review each resident's risk factors for falling, inform resident and / or resident's representative (if resident has no capacity to understand or make decision).
a. Examples of risk factors for falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension, and medical conditions affecting the central nervous system.
4.The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications that cause dizziness or hypotension) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant).
a. Falls often have medical causes; they are not just a nursing issue.
Nov 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, facility failed to ensure removal and discarding of discontinued medications for four of fou...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, facility failed to ensure removal and discarding of discontinued medications for four of four sampled discharged residents (Resident 8, 9, 10 and 14) from the medication storage room per facility's policy.
This deficient practice resulted in unsafe storage of the medication, and possibly Residents 8, 9, 10 and 14 inabilities to get the prescribed medications paid by residents ' insurance.
Findings:
1. A review of Resident 8 ' s admission Record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), dysphagia (difficulty swallowing food or liquid) and dysarthria (difficulty in speaking /slurred speech). Resident 8 was discharged on 3/23/2023.
A review of Resident 8's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 2/27/2023, indicated Resident 8 has moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and requiring limited assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene).
During a concurrent observation in the medication room and interview with the Director of Nursing (DON) on 11/27/2023 at 2:20 p.m., observed Resident 8 ' s medication bubble packs (medication packaging dispensing system) inside the medication cabinet for the following medication:
· Eliquis (blood thinner medication) 5 milligram (mg) tablet by mouth twice daily
· tamsulosin hydrochloride (hcl) (medication that relaxes bladder and prostate [accessory gland of the male reproductive system])0.4 mg capsule by mouth at bedtime,
DON verified and stated that Resident 8 had been discharged . DON stated that it should have been given to the resident or discarded by the night shift nurse.
2. A review of Resident 9 ' s admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), hypoxia (absence of enough oxygen in the tissue to sustain bodily functions) and abnormalities of gait and mobility. Resident 9 was discharged on 2/21/2023.
A review of Resident 9's MDS, dated [DATE], indicated Resident 9 has intact cognition for daily decision-making and requiring limited to extensive assistance from staff for ADLs.
During a concurrent observation in the medication room and interview with the DON on 11/27/2023 at 2:21 p.m., observed Resident 9 ' s medication bubble packs inside the medication cabinet for the following medications:
· Rosuvastatin calcium (medication that treat high cholesterol level in blood) 10 mg tablet by mouth at bedtime
· Hydralazine (medication for high blood pressure) 50 mg tablet by mouth three times a day.
DON verified and stated that Resident 9 had been discharged . DON stated that it should have been given to the resident or discarded by the night shift nurse.
3. A review of Resident 10 ' s admission Record indicated Resident 10 was admitted to the facility on [DATE], with diagnoses including end stage renal disease (ESRD-a medical condition in which a person ' s kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). Resident 10 was discharge on [DATE].
A review of Resident 10's MDS, dated [DATE], indicated Resident 10 has intact cognition for daily decision-making and requiring limited to extensive assistance from staff for ADLs.
During a concurrent observation in the medication room and interview with the DON on 11/27/2023 at 2:22 p.m., observed Resident 10 ' s medication bubble packs inside the medication cabinet for the following medications:
· Warfarin sodium (blood thinner) 2.5 mg tablet by mouth daily
· Metoprolol (medication for high blood pressure) 50 mg tablet by mouth daily
· Mycophenolate (medication to prevent organ rejection) 500 mg tablet by mouth two times per day
· Prednisone (anti-inflammation medication) 20 mg tablet by mouth two times per day
DON verified and stated that Resident 10 had been discharged . DON stated that it should have been given to the resident or discarded by the night shift nurse.
4. A review of Resident 14 ' s admission Record indicated Resident 14 was admitted to the facility on [DATE], with diagnoses including osteoporosis (a condition in which bones become weak and brittle), left artificial hip joint and hyperlipidemia (abnormally high levels of fats in the blood). Resident 14 was discharge on [DATE].
A review of Resident 14's MDS, dated [DATE], indicated Resident 14 has intact cognition for daily decision-making.
During a concurrent observation in the medication room and interview with the DON on 11/27/2023 at 2:23 p.m., observed Resident 14 ' s medication bubble packs inside the medication cabinet for the following medications:
· Levothyroxine (medication to produce thyroid gland hormone) 150 microgram (mcg) tablet by mouth daily
· Methocarbamol (muscle relaxant medication) 500 mg tablet by mouth three times daily
· Ondansetron (medication for nausea) 4 mg tablet by mouth every eight hours as needed
· Celexa (anti-depressant medication) 20 mg tablet by mouth daily
· Simvastatin (medication that treat high cholesterol level in blood) 20 mg tablet by mouth at bedtime
DON verified and stated that Resident 14 had been discharged . DON stated that it should have been given to the resident or discarded by the night shift nurse.
A review of the facility ' s policy and procedures (P&P), titled, Storage of Medications, revised on 4/2023, P&P indicated that the facility stores all drugs, and biologicals in a safe, secure and orderly manner. P&P also indicated that discontinued, outdated or deteriorated drugs are returned or destroyed.
A review of the facility ' s P&P, titled, Discarding and Destroying Medications, reviewed on 4/2023, P&P indicated that the medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances.
Nov 2023
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident's right to be treated and dignity ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident's right to be treated and dignity and to self-determination for two of the 15 sampled residents when:
1. Licensed Vocational Nurse 3 (LVN 3) asked Resident 64 what was Oxycodone (controlled strong pain medication) the maximum dose per day.
2. Resident 4 (female) shared a bathroom with male residents.
As a result, Resident 67 felt uncomfortable and Resident 4 felt bad and disgusted every time she had to use the bathroom.
Findings:
1a. A review of Resident 4's admission Record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses including dislocation of internal right hip prosthesis (when the ball of the new hip implant comes out of the socket), history of falling, and insomnia (a common sleep disorder where you may have trouble falling asleep, staying asleep, or getting good quality sleep).
A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/8/2023, indicated Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required supervision from staff for ADLs (toileting hygiene, shower/bathe, lower body dressing, putting on/taking off footwear, personal hygiene, and picking up object).
During a concurrent observation and interview with Resident 4 on 11/11/23 at 4:58 p.m., Resident 4's room bathroom was adjoined with the next room bathroom occupied by male residents. Resident 4 stated that she constantly felt bad and disgusted every time she had to use the bathroom because she had to share the bathroom with male residents. Resident 4 stated that she often found urinals (device for collecting urine) which made her feel even worse.
A review of the facility's policy and procedures (P&P) titled, Resident Rights Guidelines for All Nursing Procedure, revised October 2023 indicated, To provide general guidelines for resident rights while caring for resident . staff must have appropriate in-service training on resident rights, including . resident dignity and respect . resident freedom of choice.
A review of the facility's P&P titled, Quality of Life-Homelike Environment, revised April 2023 indicated, Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. It further indicated staff shall provide person centered care that emphasizes the residents' comfort, independence, and personal needs and preferences.
1b. A review of Resident 64's admission Record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses including displaced fracture (break in bone) in left tibia (also known as the shinbone or shank bone, is the larger, stronger, and anterior [frontal] of the two bones in the leg below the knee), and fracture of left lower leg, depression (a mood disorder that causes persistent feeling of sadness and loss of interest), and sciatica (pain, weakness, numbness, or tingling in the leg).
A review of the MDS dated [DATE], indicated Resident 64's cognitive skills for daily decision-making were intact and required supervision to moderate assistance from staff for activities of daily living (ADLs- sit to lying, chair to bed transfer, toilet transfer, and walking 10 feet).
A review of Resident 64's medication order indicated, oxycodone 10 milligram (mg - unit of measurement) every 3 hours as needed for severe pain.
During an interview with Resident 64 on 11/11/2023 at 12:24 p.m., Resident 64 stated she was experiencing severe pain and would request pain medication per physician's order. Resident 64 stated, during the first few days of admission, LVN 3 asked her if she know the maximum dosage of oxycodone she could take in a day. Resident 64 further stated, she felt uncomfortable when LVN 3 asked her the maximum dose of Oxycodone. Resident 64 stated LVN 3 was supposed to have information of Oxycodone. Resident 64 stated, she was aware that her physician ordered that she takes Oxycodone every 3 hours as needed. Resident 64 stated, she talked to the Director of Nursing (DON) regarding the incident with LVN 3.
During an interview with the DON on 11/12/2023 at 4:37 p.m., the DON stated Resident 64 was concerned about the nurses educating her on the oxycodone's maximum dosage instead of providing Resident 64 with the pain medication as per physician's order. The DON stated staff should provide residents' care with dignity and respect and to provide medications as ordered by the physician.
A review of the facility's P&P titled, Resident Rights Guidelines for All Nursing Procedure, revised October 2023, indicated, To provide general guidelines for resident rights while caring for resident . staff must have appropriate in-service training on resident rights, including . resident dignity and respect . resident freedom of choice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the licensed nursing staff failed to ensure that the residents and/or respon...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the licensed nursing staff failed to ensure that the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for one of 15 sampled residents (Resident 38).
This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications.
Findings:
A review of Resident 38's admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat), and encephalopathy (any disease that affects the whole brain and alters its structure or how it works, and causes changes in mental function).
A review of Resident 38's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 10/27/2023, indicated Resident 38 was moderate cognitive impairment (a condition in which people have more memory or thinking problems than other people their age) and was dependent for toileting hygiene, lower body dressing, putting on/taking off footwear, sitting to lying. It also indicated he required substantial/maximum assistance roll left and right oral hygiene, and shower/bathe self.
During a concurrent interview and record review of the physician's orders with the Director of Nursing on 11/12/23 at 7:41 p.m., the DON confirmed that Resident 38 had an order of escitalopram (Lexapro - used to treat depression and anxiety. It works by helping to restore the balance of a certain natural substance (serotonin) in the brain) 10 mg to be given by mouth at night for depression manifested by verbalization of sadness but had not signed consent. Resident also had an order of buspirone (Buspar- an anxiolytic agent used for short-term treatment of generalized anxiety and second-line treatment of depression) 10 mg tabs to be given by mouth daily with no consent on file. The DON admitted that the consents had not been signed and that the facility should have a consent on file so that residents receive treatments that they are consenting to.
A review of the facility's policy and procedures titled Psychotropic Medication Use Policy, revised January 2023 indicated, It is the policy of this facility that: All residents receiving psychotropic medication(s) prescribed for control of a specific behavior or manifestation of a disordered thought process shall be monitored for effectiveness of the medication and for adverse drug reactions. It further indicated the resident or designated responsible party has the right to make decisions with regard to his/her medical condition, to receive information related to the need for and the risks related to the use of psychotherapeutic drugs. The resident likewise shall be advised that he/ she has the right to accept or refuse the proposed treatment. It also indicated, the Attending Physician shall be responsible for informing the resident prior to the first use of Psychotherapeutic drug and for Verification of Informed Consent to the facility. The facility shall be responsible for documenting Verification of Informed Consent.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a preadmission screening assessment was completed for o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a preadmission screening assessment was completed for one of threee sampled residents (Resident 21), who was diagnosed with a mental illness prior to admission in the facility.
This deficient practice had the potential for Resident 21 not receiving the necessary and appropriate psychiatric (relating to mental illness or its treatment) level of treatment and evaluation in the facility.
Cross Reference: F641.
Findings:
A review of Resident 21's admission Record indicated Resident 21 was admitted to the facility on [DATE], with diagnoses including chronic hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and radiculopathy (injury or damage to nerve roots in the area where they leave the spine).
A review of Resident 21's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 9/13/2023, indicated Resident 21's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired and required extensive assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use).
A review of Resident 21's Preadmission Screening and Resident Review (PASARR) indicated, the PASARR screening was completed on 11/11/2023.
During an interview with the Director of Nursing (DON), on 11/12/2023 at 3:57 p.m., the DON stated PASARR was to be completed within 24 hours of admission/re-admission or prior to admission. The DON stated Resident 21's PASARR screening was not completed timely.
A review of the facility's policy and procedures (P&P) titled, Preadmission Screening & Resident Review (PASARR), revised on May 2023 indicated, PASARR requires that all applicants . to be evaluated for a serious mental disorder and/or intellectual disability . the facility will obtain/complete a Preadmission Screening and Resident Review timely . pre-admit and date of PASARR should be the same day of admit as stated above. DON or Registered Nurse (RN) will complete the PASARR before admitting a resident from home or senior living facilities or on admission date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. A review of Resident 6's admission Record indicated Rresident 6 was admitted to the facility on [DATE], with diagnoses inclu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. A review of Resident 6's admission Record indicated Rresident 6 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 6's MDS dated [DATE], indicated Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required maximal to dependence from staff for activities of daily living (ADLs- oral hygiene, toileting, shower/bathing, personal hygiene). The same MDS further indicated, Resident 6 was on physical restraints using bed rails daily.
A review of Resident 6's Physician's Order Summary Report, dated 11/10/2023 indicated, 1/4 SR (Side rail) up while in bed as enabler for mobility and ¼ SR up while in bed for safe turning and repositioning.
A review of Resident 6's Safety Device/Mobility Device assessment dated [DATE] indicated, Resident 6 was observed to be able to use side rail for bed mobility with recommendations to use both sides, ¼ side rails for mobility device.
A review of Resident 6's care plan for ¼ bed SR as enabler to assist with bed mobility, initiated on 10/29/2023 had a goal of will continue to utilize the ¼ SR to assist with turning, repositioning, or transfer.
During an observation with Resident 6 on 11/10/2023 at 11:36 a.m., Resident was observed with bilateral upper siderails up.
2b. A review of Resident 28's admission Record indicated Resident 28 was admitted to the facility on [DATE], with diagnoses including intervertebral disc degeneration (when the spinal disks wear down), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest).
A review of Resident 28's MDS dated [DATE], indicated Resident 28's cognitive skills for daily decision-making were severely impaired and required maximal assistance from staff for ADLs- oral hygiene, lower body dressing, sit to lying and to stand and walking 10 feet. The same MDS further indicated, Resident 28 was on physical restraints using bed rails daily.
A review of Resident 28's Physician's Order Summary Report, dated 10/13/2023 indicated, 1/4 SR up while in bed as enabler for mobility and ¼ SR up while in bed for safe turning and repositioning.
A review of Resident 28's Safety Device/Mobility Device Assessment, dated 10/13/2023 indicated, Resident 28 was observed to be able to use side rail for bed mobility with recommendations to use both sides, ¼ side rails for mobility device.
A review of Resident 28's care plan for ¼ bed SR as enabler to assist with bed mobility, initiated on 10/13/2023 had a goal of will continue to utilize the ¼ SR to assist with turning, repositioning, or transfer.
During an observation with Resident 6 on 11/10/2023 at 11:12 a.m., Resident 28 was observed with bilateral upper siderails up.
2c. A review of Resident 38's admission record indicated the Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) metabolic 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) and primary osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down).
A review of the MDS dated [DATE], indicated Resident 38's skills for daily decision-making were moderately impaired and required maximal assistance to dependent from staff for ADLs- roll left and right, sit to lying, lying to sitting and car transfer. The MDS also indicated that Resident 38 is on physical restraints using bed rails daily.
A review of Resident 38's Physician's Order Summary Report, dated 10/23/2023 indicated, 1/4 SR up while in bed as enabler for mobility and ¼ SR up while in bed for safe turning and repositioning.
A review of Resident 38's Safety Device/Mobility Device Assessment, dated 10/23/2023 indicated, Resident 38 was observed to be able to use side rail for bed mobility with recommendations to use both sides, ¼ side rails for mobility device.
A review of Resident 38's care plan for ¼ bed SR as enabler to assist with bed mobility, initiated on 10/23/2023 had a goal of will continue to utilize the ¼ SR to assist with turning, repositioning, or transfer.
During an observation with Resident 38 on 11/10/2023 at 11:28 a.m., Resident 38 was observed with bilateral upper siderails up.
During an interview with DON on 11/12/2023 at 4:51 p.m., DON stated, they utilize bed rails up as enablers for mobility with physician's order of ¼ SR up. DON stated, the nurse's safety device/mobility device assessment does not correlate together with physician's order as indicated ¼ SR up, and the safety device/mobility device assessment indicated both sides, bed SR up. The DON further stated, ¼ side rails was not the same as both sides side rails up. DON stated, the facility did not follow physician's order as well as did not implement the care plan's interventions for use of side rails.
A review of the facility's P&P titled, Care Plans - Comprehensive, revised September 2023 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 . care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes.
Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for four of 35 sampled residents (Residents 6, 16, 28 and 38) by failing to ensure:
1. Comprehensive care plan was developed and implemented for Resident 16's levetiracetam (medication to treat seizure [a sudden, uncontrolled electrical disturbance in the brain]) use.
2. Residents 6, 28 and 38 had the proper care plan for bed side rails per physician order.
These deficient practices had the potential to result negative impact on Residents 6, 16, 28 and 38's health and safety, as well as the quality of care and services received.
Findings:
1. A review of Resident 16's admission Record, indicated the facility admitted Resident 16 on 9/13/2023 with diagnoses including osteoporosis (a condition in which bones become weak and brittle), Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease).
A review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/5/2023, the MDS indicated Resident 16's cognitive skill for daily decision-making was severely impaired and with moderate to maximal assistance for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene).
A review of Resident 16's Order Summary Report, dated 9/13/2023 indicated Resident 16 had an order for levetiracetam 500 milligram (mg) by mouth two times a day for seizure.
During a concurrent record review and interview with the Director of Nursing (DON), on 11/12/2023 at 7:27 p.m., Resident 16' s chart was reviewed. Resident 16's chart indicated missing care plan for levetiracetam use. DON verified and stated that Resident 16 should have a care plan for levetiracetam use.
A review of the facility's policy and procedures (P&P) titled, Care Plans - Comprehensive, revised September 2023 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 . care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 9) psych...
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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 22 sampled residents (Resident 9) psychoactive medication clonazepam (klonopin- a long-acting benzodiazepine with intermediate onset commonly used to treat panic disorders, severe anxiety, and seizures)
1. Was necessary to treat a specific diagnosis and documented condition.
2. Pharmacist recommendations were followed.
This deficient practice had the potential to place Resident 9 at risk of receiving unnecessary medication.
Findings:
A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause with above-normal blood pressure is typically anything over 120/80), malignant neoplasm of prostate (Prostate cancer is cancer that occurs in the prostate. The prostate is a small walnut-shaped gland in males that produces the seminal fluid), and radiculopathy, lumber region (an inflammation of a nerve root in the lower back, which causes symptoms of pain or irritation in the back and down the legs).
A review of Resident 9's history and physical (the most formal and complete assessment of the patient and the problem. Physicians documentation are produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending) dated 10/16.2023 indicated, Resident 9 had the capacity to understand and make decisions.
During an interview with Resident 9 on 11/10/2023 at 11:46 a.m., Resident 9 stated that he was unable to sleep well at night because his roommate coughs throughout the night. He stated that he had made the staff, the Director of Nursing (DON) aware about these issues and was offered a room change.
A review of the physician's order dated 11/10/2023 indicated clonazepam tablet 0.5 mg tablet by mouth at bedtime for anxiety manifested by inability to sleep.
During a concurrent interview and record review with the DON on 11/12/23 at 11:44 a.m., the DON stated that whenever a resident is having a hard time sleeping, a room change is offered if it is because of environmental factors. If disturbance not due to environmental factors, then routines such as set times for sleeping then eventually sleep medications are added. The DON confirmed and stated that Resident 9 did not have a diagnosis for anxiety. He stated that having a diagnosis for ordered medications especially psychoactive medications to ensure that the resident was receiving treatments for a condition that had been diagnosed.
A review of the facility's policy and procedures titled Psychotropic Medication Use Policy, revised January 2023 indicated, It is the policy of this facility that:
All residents receiving psychotropic medication(s) prescribed for control of a specific behavior or manifestation of a disordered thought process shall be monitored for effectiveness of the medication and for adverse drug reactions. The same policy further indicated the resident or designated responsible party has the right to make decisions with regard to his/her medical condition, to receive information related to the need for and the risks related to the use of psychotherapeutic drugs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the appropriate setting of the low air loss mat...
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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 appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up for two of two sampled residents, (Residents 38 and 57) according to the residents' needs and professional standard of care.
This deficient practice placed Residents 38 and 57 at risk of poor wound healing of the current pressure ulcer (skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin) and had a potential to develop new pressure sores/wounds.
Findings:
A. A review of Resident 38's admission record indicated Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) metabolic 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) and primary osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down).
A review of Resident 38's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/27/2023, indicated Resident 38's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired and required maximal assistance to dependent from staff for activities of daily livings (ADLs- roll left and right, sit to lying, lying to sitting and car transfer). The same MDS further indicated that Resident 38 has a pressure ulcers/injury and is using a pressure reducing device for bed.
A review of Resident 38's care plan for at risk for skin breakdown, initiated on 10/23/2023 indicated a goal of, resident will be free of skin breakdown, with interventions that included, pressure relieiving device while in bed and in wheelchair
A review of Resident 38's Physician Order Summary Report, dated 11/2/2022 indicated, an order for LAL related to pressure injury every day per shift.
A review of Resident 38's Weights and Vitals Summary, dated 11/8/2023 indicated Resident 38's weight was 188.4 pounds (lbs.).
During an observation of Resident 38 on 11/10/2023 at 11:28 a.m., observed Resident 38 lying on a bed with a LAL mattress with the machine turned off.
During an observation of Resident 38 on 11/10/2023 at 12:45 p.m., observed Resident 38 lying on a bed in a LAL mattress with the setting at 120 lbs.
During a concurrent interview with Registered Nurse 1 (RN 1) and observation with Resident 38 on 11/10/2023 at 4:40 p.m., RN 1 stated, the LAL mattress for Resident 38 was set to 120 lbs. RN 1 stated, Resident 38 does not weight 120 lbs and the setting for the LAL mattress was incorrect.
A review of the facility's policy and procedures (P & P) titled, Support Surface Guidelines, revised on April 2023 indicated, The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown.
B. A review of Resident 57's admission Record, indicated the facility admitted Resident 57 on 10/23/2023 with diagnoses including osteoporosis (a condition in which bones become weak and brittle), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body).
During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57's cognitive skill for daily decision-making was moderately impaired and with moderate assistance for ADLs- bed mobility, dressing, toilet use, and personal hygiene). MDS also indicated Resident 57 was at risk for developing pressure ulcers /injuries and receiving treatment such as pressure reducing device for bed.
During a review of Resident 57's Order Summary Report, dated 11/11/2023. The Order Summary Report indicated Resident 57 had an order for low air loss mattress for wound prevention and comfort.
During a review of Resident 57's chart, Resident 57 weighed 111.6 lbs. on 10/25/2023.
During a concurrent observation and interview on 11/10/2023 at 12:50 p.m., Resident 57 was observed laying in a LAL mattress bed at a setting of 240 lbs. Resident 57 stated being uncomfortable.
During an interview with the Director of Staff and Development (DSD), on 11/10/2023 at 12:52 p.m., the DSD stated that LAL mattress should be set by weight and comfort of the resident.
During an interview with the Treatment Nurse 1 (TN 1), on 11/11/2023 at 12:55 p.m., the TN1 stated that LAL mattress setting should be based on resident's weight and comfort.
A review of facility's P&P, titled, Support Surface Guidelines, reviewed on 4/2023, 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.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Pe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Personal Alarms, for one of 22 sampled residents, (Resident 28) who are at risk for falls.
This deficient practice placed Resident 28 at risk for fall and sustain an accidental injury.
Findings:
A review of Resident 28's admission Record indicated Resident 28 was admitted to the facility on [DATE], with diagnoses including intervertebral disc degeneration (when the spinal disks wear down), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest).
A review of Resident 28's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/17/2023, indicated Resident 28's cognitive skills for daily decision-making were severely impaired and required maximal assistance from staff for activities of daily living (ADLs- oral hygiene, lower body dressing, sit to lying and to stand and walking 10 feet).
A review of Resident 28's Physician's Order Summary Report, dated 10/13/2023 indicated, Monitor tab alarm placement and functionality every shift.
A review of Resident 28's care plan for at risk for falls related to weakness, initiated on 10/13/2023, had a goal of, Resident will have no incident of falls/injury every shift, with interventions that included, maintain a safe and hazard free environment .
During an observation with Resident 28 on 11/10/2023 at 4:07 p.m., observed Resident 28 lying on a bed with the tab (personal) alarm disconnected from the electric cord and from the resident, and the alarm was on the floor.
During a concurrent observation and interview with Certified Nursing Assistant 1 (CNA 1), on 11/10/2023 at 4:09 p.m., CNA 1 stated and confirmed, the tab (personal) alarm was disconnected from the electric power cord and from Resident 28's clothing, therefore it won't work.
During an interview with Licensed Vocational Nurse (LVN 2), on 11/10/2023 at 4:12 p.m., LVN 2 stated, the tab (personal) should be connected to the electric power cord and to the resident for it to alarm when resident tries to get out of bed on their own. LVN 2 stated, if the device used to prevent falls is not working properly, then it puts Resident 28 at risk for falls.
A review of the facility's P&P titled, Personal Alarms, revised May 2023 indicated, Nursing staff will check placement of the device alarm, function and continue need during the shift.
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 staff failed to ensure resident received appropriate treatment a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) for one of three sampled residents (Resident 177) by failing to ensure Resident 177's indwelling urinary (foley) catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) was placed below the level of the bladder at all times.
This deficient practice had the potential to result in urinary tract infections for Resident 177.
This deficient practice had the potential for Resident 177 to be at risk for complications related to indwelling catheters such as UTI.
Findings:
A review of Resident 177's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), anemia (a condition which the blood does not have enough health red blood cells), and retention of urine (a condition in which you are unable to empty all the urine from your bladder).
A review of Resident 177's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 11/10/2023, indicated Resident 177's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required moderate assistance from staff for activities of daily living (ADLs- toileting, shower/bathing, lower body dressing).
A review of Resident 177's Care Plan for potential reoccurrence of bladder infection related to history of UTI and use of catheter, dated initiated on 11/6/2023, with a goal of will be able to assess signs and symptoms of bladder infection and prevent reoccurrence, had an intervention to, observe for signs of UTI . and turn and reposition at regular intervals to prevent urine stagnation.
During the facility tour on 11/10/2023 at 11:17 a.m., observed Resident 177 lying in the bed with a urinary catheter placed higher than level of her bladder and the urine in the tubing was observed flowing back to her blader, not in the urinary drainage bag.
During a concurrent observation and interview with Director of Staff and Development (DSD), on 11/10/2023 at 11:26 a.m., DSD observed and confirmed, Resident 177's urinary catheter drainage bag was placed higher than her [Resident 177] bladder, with the urine backflowing in the bladder. DSD stated the urinary drainage bag was placed incorrectly and should be placed below her [Resident 177] bladder to prevent backflowing of the urine. DSD further stated, this placed Resident 177's at risk of UTI.
A review of the facility's policy and procedures (P&P) titled, Catheter Care, Urinary, revised on September 2023 indicated, the purpose of this procedure is to prevent catheter-associated urinary tract infections . the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that two of 15 sampled residents (Residents 11...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that two of 15 sampled residents (Residents 11 and 36) were accurately assessed and monitored by failing to:
1. Identify and assess prevent unplanned significant weight loss of 11.4 pounds (lbs) (6.8 percent) in 9 days for Resident 11.
2. Ensure Resident 36 who was on a fluid restriction, received the daily fluids per physician's order and resident's care plan.
These deficient practices resulted in Resident 11 having unplanned significant weight loss of 11.4 pounds in 10 days and placed her at a risk for malnutrition; it also had the potential to cause either fluid overload or dehydration for Resident 36.
Findings:
A. A review of Resident 1's admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including hypothyroidism (the thyroid gland [butterfly-shaped gland in the front of the neck] does not produce adequate thyroid hormones to meet the body's needs), overactive bladder (OAB-causes a frequent and sudden urge to urinate that may be difficult to control), and gastro-esophageal reflux disease (GERD-occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]) with esophagitis (inflammation or irritation of the esophagus).
A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 10/27/2023, indicated Resident 11 was cognitively (relating to mental ability to make decisions of daily living) intact and required supervision assistance for eating, oral hygiene, personal hygiene. Resident 11 required partial/maximum assistance for upper body dressing. The MDS further indicated that Resident 11 required substantial/maximum assistance for putting on/taking off footwear, rolling left and right, sitting to lying, and sitting to standing.
During a concurrent interview and record review of the weight log for Resident 11with Director of Nursing (DON) on 11/12/23 08:20 a.m., the DON confirmed that Resident 11 had a weight loss of 11.4 lbs. between 10/25/2023, weighted 167.8 lbs. and 11/3/23, weighted 156.4 lbs. The DON stated the weight loss was considered significant, adding that the facility protocol when there is significant weight loss is to notify the physician with SBAR (Situation, Background, Assessment, Recommendation- an easy to use, structured form of communication that enables healthcare professionals communicate quickly, efficiently, and effectively), to place the resident on monitoring (for weight and oral intake). The DON also stated the assessment and reviews from Registered Dietician (RD) and Interdisciplinary team meeting (IDT-a group of health care professionals with various areas of expertise who work together toward the goals of their clients)-need be completed as soon the significant weight loss is determined. The DON stated the potential of not addressing the loss would result in the resident's nutritional needs not being met.
During an interview with the RD on 11/12/23 at 4:30 p.m., the RD stated she saw Resident 11 on 11/10/2023. The RD also stated that Resident 11 had a significant weight loss that should have been flagged and addressed as soon as it was identified. The RD further stated the potential for the weight loss not being addressed would place Resident 11 at a risk for malnutrition.
A review of the policy and procedure titled Weight Assessment and Intervention, revised May 2023, indicated, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. It further indicated weight assessment:
1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks.
2. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record.
3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing.
4. The Dietitian will review the weekly and monthly Weight Record and follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met.
5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight- actual weight)/ (usual weight) x 100]:
a. 1 month - 5% weight loss is significant; greater than 5% is severe.
b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe.
c. 6 months - 10% weight loss is significant; greater than 10% is severe.
6. If the weight change is desirable, this will be documented and no change in the care plan will be necessary.
B. A review of Resident 36's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (also known as a stroke- refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, end stage renal disease (ESRD-a medical condition in which a person's kidney stops functioning on a permanent basis), and congestive heart failure (a condition in which the heart does not pump blood as well as it should).
A review of the MDS dated [DATE], indicated Resident 36's cognitive skills for daily decision-making were moderately impaired and required moderate assistance from staff for ADLs (activities of daily living- such as oral hygiene, toileting, shower/bathing, lower body dressing).
A review of Resident's 36's Physician Order Summary Report, dated 11/8/2023 indicated an order: fluid restriction 1500-millimeter (ml) per day, nursing to provide 540 ml/day; 200 ml on morning (AM) shift, 200 ml on evening (PM) shift, 140 ml on night (NOC) shift; dietary to provide 960ml-breakfast 480ml, lunch 240ml, dinner 240ml for chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure).
A review of Resident 36's care plan for nutritional problem related to .CKD, initiated on 1/17/2022, indicated a goal of resident will maintain adequate nutritional status as evidenced by having no weight significant weight changes, with interventions that included, fluid restriction 1500 ml/day .
A review of the Medication Administration Record (MAR) for the month of November 2023 indicated physician's order of fluid restrictions: 1500 ml/day nursing to provide 540 ml/day; AM shift - 200 ml - PM shift - 200 ml; NOC shift - 140 ml; (dietary to provide 960 ml/day). The MAR for November 2023 indicated the following fluid intakes:
I.
11/1/2023 - on AM shift, nurses provided 920 ml of fluid; PM shift: 440 ml, NOC shift: 140 ml (total of 1500 ml)
II.
11/2/2023 - AM shift - 920 ml; PM shift - 440 ml; NOC shift - 140 (total of 1500 ml)
III.
11/3/2023 - AM shift - 920 ml; PM shift - 440 ml; NOC shift - 70 (total of 1430 ml)
IV.
11/4/2023 - AM shift - 920 ml; PM shift - 440 ml; NOC shift - 60 (total of 1420 ml)
V.
11/5/2023 - AM shift - 900 ml; PM shift - 360 ml; NOC shift - 60 (total of 1320 ml)
VI.
11/6/2023 - AM shift - 900 ml; PM shift - 400 ml; NOC shift - 140 (total of 1440 ml)
VII.
11/7/2023 - AM shift - 400 ml; PM shift - 440 ml; NOC shift - 140 (total of 980 ml)
VIII.
11/9/2023 - AM shift - 1160 ml; PM shift - 440 ml; NOC shift - 60 (total of 1660 ml)
IX.
11/10/2023 - AM shift - 1160 ml; PM shift - 440 ml; NOC shift - 120 (total of 1720 ml)
During a concurrent interview with Director of Nursing (DON) and record review of Resident 36's medical record on 11/12/2023 at 4:07 p.m., the DON stated and confirmed, Resident 36's fluid restrictions were not followed by the nursing staff. The DON stated the resident's target weight was not being met because of the fluid overload, which placed Resident 38 at risk of over hydration.
A review of the facility's P&P titled, Dialysis care, revised May 2023 indicated, monitor intake and output as ordered. Observe fluid restrictions as ordered by the physician.
A review of the facility's P&P titled, Intake and Output Policy, revised May 2023 indicated, to provide an accurate record of identified resident's intake and output (I&O) . The license nurse will total the intake by adding the intake reported from Certified Nursing Assistants (CNAs) and the fluid gave with med pass . The license nurse will record the total intake and output on the MAR at the end of each shift.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to effectively manage pain for one of 15 sampled resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to effectively manage pain for one of 15 sampled residents (Resident 64) by not following physician's medication order.
This deficient practice resulted in Resident 64 experienced unnecessary pain.
Findings:
A review of Resident 64's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including displaced fracture (break in bone) in left tibia (also known as the shinbone or shank bone in the leg below the knee), and fracture of left lower leg, depression (a mood disorder that causes persistent feeling of sadness and loss of interest), and sciatica (pain, weakness, numbness, or tingling in the leg).
A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/30/2023, indicated Resident 64's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact. Resident 64 required supervision to moderate assistance from staff for activities of daily living (ADLs- daily activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating).
A review of Resident 64's Physician Order Summary Report dated 9/30/2023 indicated, oxycodone (medication that can treat moderate to severe pain) 5 milligram (mg) every 4 hours as needed for mild pain.
A review of Resident 64's Care Plan for alteration in comfort, pain, initiated on 10/27/2023, indicated a goal of pain is decreased or controlled as evidenced by decreased # of requests for pain medications (meds) and/or verbalization that pain is tolerable with interventions that includes, to administer meds as ordered, monitor for effectiveness, notify medical doctor (MD) if ineffective.
A review of Resident 64's Medication Administration Record (MAR) for the month of October indicated: oxycodone 5mg - give 1 tablet every 4 hours as needed for mild pain, was administered on:
i.
10/1/2023 at 12:36 p.m. - Resident 64's pain level of eight out of 10 (8/10 - numerical pain assessment where zero is no pain and 10 is most severe pain).
ii.
10/1/2023 at 5:55 p.m. - pain level of 8/10
iii.
10/1/2023 at 10:41 p.m. - pain level of 8/10
iv.
10/2/2023 at 6:05 a.m. - pain level of 7/10
v.
10/3/2023 at 12:34 p.m. - pain level of 7/10
vi.
10/4/2023 at 4:04 a.m. - pain level of 7/10
vii.
10/6/2023 at 5:26 a.m. - pain level of 0/10
viii.
10/7/2023 at 4:58 a.m. - pain level of 7/10
During an interview with Resident 64 on 11/11/2023 at 12:24 p.m., Resident 64 stated she was experiencing severe pain and would request pain medication per physician's order. Resident 64 stated, her pain was not being managed properly as she had experienced pain constantly. Resident 64 stated, she her pain level was 8/10 throughout the day.
During an interview with Director of Nursing (DON) on 11/12/2023 at 4:37 p.m., the DON stated, pain level of 1-3/10 is mild pain, and 6-10/10 is severe pain. The DON stated, for resident experiencing severe pain, staffs should administer pain medications for severe pain following the physician's order. The DON stated, Resident 64 was given pain medications for mild pain instead of severe pain as Resident 64 reported her pain level was 8/10. The DON stated Resident 64's pain was not managed properly.
A review of the facility's policy and procedure (P&P) titled, Pain Management, revised March 2023 indicated, The nursing staff will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity.
A review of the facility's P&P titled, Pain Assessment and Management, revised March 2022, The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . pain management interventions shall reflect the sources, type and severity of pain.
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 to ensure one of the 22 sampled residents (Resident 9) p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of the 22 sampled residents (Resident 9) psychoactive medication clonazepam (klonopin- a long-acting benzodiazepine with intermediate onset commonly used to treat panic disorders, severe anxiety, and seizures [is a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness]), by failing to ensure:
1. Klonopin was necessary to treat a specific diagnosis and the condition documented.
2. The Pharmacist's recommendations were followed.
These deficient practice had the potential to place Resident 9 at risk of receiving unnecessary medication.
Findings:
A review of Resident 9's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause with above-normal blood pressure is typically anything over 120/80), malignant neoplasm of prostate (Prostate cancer is cancer that occurs in the prostate. The prostate is a small walnut-shaped gland in males that produces the seminal fluid), and radiculopathy, lumber region (an inflammation of a nerve root in the lower back, which causes symptoms of pain or irritation in the back and down the legs).
A review of Resident 9's history and physical (the most formal and complete assessment of the patient and the problem. Physicians documentation are produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending) dated 10/16.2023 indicated, Resident 9 had the capacity to understand and make decisions.
During an interview with Resident 9 on 11/10/2023 at 11:46 a.m., Resident 9 stated that he was unable to sleep well at night because his roommate coughs throughout the night. Resident 9 further stated that he had made the staff and the Director of Nursing (DON) aware about these issues and was offered a room change.
A review of the physician's order dated 11/10/2023 indicated clonazepam tablet 0.5 mg tablet by mouth at bedtime for anxiety manifested by inability to sleep.
During a concurrent interview and record review with the DON, on 11/12/23 at 11:44 a.m., the DON stated that whenever a resident is having a hard time sleeping, a room change is offered if it is because of environmental factors. If disturbance not due to environmental factors, then routines such as set times for sleeping then eventually sleep medications are added. The DON admitted that Resident 9 did not have a diagnosis for anxiety. The DON further stated that having a diagnosis for ordered medications especially psychoactive medications, staff have to ensure that the resident was receiving treatments for a condition that had been diagnosed.
A review of the facility's policy and procedures titled Psychotropic Medication Use Policy, revised January 2023 indicated, It is the policy of this facility that:
All residents receiving psychotropic medication(s) prescribed for control of a specific behavior or manifestation of a disordered thought process shall be monitored for effectiveness of the medication and for adverse drug reactions. It further indicated the resident or designated responsible party has the right to make decisions with regard to his/her medical condition, to receive information related to the need for and the risks related to the use of psychotherapeutic drugs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 7's) psychotrop...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 7's) psychotropic (relating to or denoting drugs that affect a person's mental state) medication regimen was managed and monitored to promote or maintain the highest practicable mental, physical, and psychosocial well-being by failing to ensure:
1. The implementation of monitoring episodes of anxiety for Resident 7's alprazolam (anti-anxiety medication) use.
2. The implementation of monitoring for any potential side effect and/or adverse reaction for Resident 7's alprazolam use.
3. The implementation of monitoring episodes of depression for Resident 7's citalopram hydrobromide (anti-depressant medication) use.
4. The implementation of monitoring for any potential side effect and/or adverse reaction for Resident 7's citalopram hydrobromide use.
5. Ensure Resident 7's citalopram hydrobromide use had indicated manifestation of behavior specific for the diagnosis.
These deficient practices had the potential to place Resident 7 at risk of receiving unnecessary medications and/or overuse of medication, and at risk for adverse consequences while taking psychotropic medications.
Findings:
A review of Resident 7's admission Record indicated the facility originally admitted Resident 7 on 9/3/2023 and readmitted on [DATE] with diagnoses including fracture of bilateral humerus (a break, crack or crush injury of the bone in both arms), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body).
A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/18/2023, indicated Resident 7's cognitive skill for daily decision-making was intact and required with one-person physical assistance for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene).
A review of Resident 7's Order Summary Report indicated Resident 7 had the following active orders:
- Citalopram Hydrobromide 20 milligram (mg) by mouth once a day for depression, ordered on 9/14/2023
-Alprazolam 1 mg by mouth tow times a day for anxiety, ordered on 11/10/2023
During a concurrent record review and interview with the Director of Nursing (DON) on 11/12/2023 at 7:32 p.m., the DON verified Resident 7's missing orders for the following:
1. Monitoring episodes of anxiety for Resident 7's alprazolam use.
2. Monitoring for any potential side effect and/or adverse reaction for Resident 7's alprazolam use.
3. Monitoring episodes of depression for Resident 7's citalopram hydrobromide use.
4. Monitoring for any potential side effect and/or adverse reaction for Resident 7's citalopram hydrobromide use.
5. Manifestation of behavior specific for the diagnosis for Resident 7's citalopram hydrobromide use.
The DON stated importance of monitoring each behavior and potential side effect/ adverse reaction of all psychotropic medications and making sure that for every psychotropic medication will have manifestations of behavior.
A review of the facility's policy and procedure (P&P), Psychotropic Medication Use Policy, revised 9/2023, indicated that for each routine and PRN psychotropic medication:
-The medication, dose and frequency will be indicated in the clinical record and consent.
-A specific condition being treated will be identified in the physician's order
- Behavior manifestations will be identified in the care plan.
- The number of behavior episodes will be collected on the medication sheet.
- A summary of behavior episodes and presence of side effects will be complied for the prescriber on a monthly basis.
- Evidence of behavior assessment and attempts at gradual dose reduction will be documented in the medical record.
- Excessive use of PRN antipsychotics will be assessed and prescriber notified.
-Recommendations for changes in psychotropic medication regimen will be directed to the prescriber.
The P&P also indicated that facility will provide a method of assessing those residents receiving psychotropic medication to ensure:
- Alternative behavior management have been attempted prior to the use of psychotropic medications.
-Behavior management are a continuing part of the resident's plan of care.
-Early identification and reporting of drug side effects.
-Summaries of resident behavior manifestation, frequency, response to behavioral programs and medications as well as recommendations for changes in medication are provided to the physician.
-Psychotropic medications are used in the lowest possible does and are discontinued when no longer required.
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** Based on interview, and record review, the facility failed to maintain accurate medical record in accordance with accepted profe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain accurate medical record in accordance with accepted professional standards and practices for one of 22 sampled residents (Resident 33) by failing to ensure Resident 33's change of condition documentation on 10/25/2023 was documented via late entry. Resident 33 was transferred to an acute care hospital (GACH) on 10/24/2023.
This deficient practice had the potential to negatively impact the delivery of service given to Resident 33.
Findings:
A review of Resident 33's admission Record indicated the facility originally admitted Resident 33 on 8/31/2023 and readmitted on [DATE] with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), urinary tract infection (UTI-a bacterial infection of the bladder and associated structures). admission Record also indicated Resident 33 was transferred to GACH on 10/24/2023.
A review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/30/2023, indicated Resident 33's cognitive skill for daily decision-making was severely impaired and required limited to extensive assistance from staff for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene).
A review of Resident 33's order summary report dated 10/24/2023, indicated an order to transfer Resident 33 to GACH for cough, abdominal pain and leukocytosis (elevated white blood cells [body cell that contains antibodies for infection]).
A review of Resident 33's SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition) dated 10/24/2023, indicated Resident 33 had a change in condition due to leukocytosis and was transferred to GACH.
A review of Resident 33's SBAR dated 10/25/2023, indicated the resident had a change in condition due to weight loss.
During an interview with Licensed Vocational Nurse 5 (LVN 5) on 11/12/2023 at 3:52 p.m., LVN 5 stated that she (LVN 5) was not supposed to complete the SBAR for weight loss if she had known at that time Resident 33 was transferred to GACH on 11/24/2023.
A review of the facility's policy and procedure (P&P), titled, Charting Errors/Omissions/Late Entry, revised 1/2023, P&P indicated that accurate medical records shall be maintained by the facility and that if there is a necessity to change or add information in the resident's medical record, it shall be completed by means of addendum and late entries in the medical record shall be dated at the time of entry and noted as a late entry.
A review of the facility's P&P, titled, Charting and Documentation, revised on 4/2023, P&P indicated all services provided to the resident or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.
A review of the facility's P&P, titled, Change in a Resident's Condition or Status, revised 9/2023, indicated that facility will promptly notify the resident's physician of the changes in resident's medical/mental condition and/or status.
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** E. A review of Resident 11's admission record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses includ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E. A review of Resident 11's admission record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including hypothyroidism (underactive thyroid [a small, butterfly-shaped gland in the front of the neck]) is when the thyroid gland does not produce adequate thyroid hormones to meet the body's needs), overactive bladder (OAB-causes a frequent and sudden urge to urinate that may be difficult to control), and hypertension (high blood pressure).
A review of Resident 11's MDS dated [DATE], indicated Resident 11 was cognitively intact and required supervision assistance for eating, oral hygiene, personal hygiene. Resident 11 required partial/maximum staff assistance for upper body dressing. The MDS further indicated that Resident 11 required substantial/maximum assistance for putting on/taking off footwear, roll left and right, sit to lying, and sit to stand.
F. A review of Resident 227's admission record indicated Resident 227 was admitted to the facility on [DATE] with diagnoses including syncope and collapse (also called fainting or passing out. It most often occurs when blood pressure is too low (a condition called hypotension) and the heart doesn't pump enough oxygen to the brain. It can be harmless or a symptom of an underlying medical condition), chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems), and paroxysmal atrial fibrillation (rapid and erratic heart rate).
A review of Resident 227's MDS dated [DATE], indicated Resident 227 had moderate cognitive impairment. The MDS indicated Resident 227 required partial/moderate staff assistance for walking 10 feet, , one step curb. Resident 227 required supervision or touch assistance for toilet hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and toilet transfer.
During a concurrent interview and record review with the SSD on 11/11/23 at 5:01 p.m., Resident 227's medical chart was reviewed and did not have an Advance The SSD stated that AD reflected and indicated who was Resident 227's next of kin. The SSD confirmed and stated that it was Resident 227's right to have an advanced directive on file and that not having them on file would result in Resident 227 receiving services against the resident's wishes.
A review of the facility's P&P titled Advance Directives, revised 1/2023 indicated Advance directives will be respected in accordance with state law and facility policy. The P&P Interpretation and Implementation indicated the following:
1. 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.
2. Written information will include a description of the facility's policies to implement advance directives and applicable state law.
3. 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.
4. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information.
5. Each resident will also be informed that the facility's policies do not condition the provision of care or discriminate against an individual based on whether or not the individual has executed an advance directive.
6. Prior to or upon admission of a resident, the social services 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.
7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.
8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.
a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision.
b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.
9. The attending physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan.
10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/ or advance directive.
11. The resident has the right to refuse treatment, whether or not he or she has an advance directive. A resident will not be treated against his or her own wishes. Residents who refuse treatment will not be transferred to another facility unless all other criteria for transfer are met.
12. Depending on state requirements, the legal representative may also have the right to refuse or forego treatment.
B. A review of Resident 21's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including chronic hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and radiculopathy (injury or damage to nerve roots in the area where they leave the spine).
A review of Resident 21's MDS dated [DATE], indicated Resident 21's cognitive skills for daily decision-making were moderately impaired and required extensive assistance from staff for ADL (bed mobility, transfer, dressing, and toilet use).
A Review of Resident 21's Advance Directive Acknowledgement form, dated 9/9/2023 indicated, Resident 21 signed and requested, would like to receive additional information, regarding the Advance Directive.
A review of Resident 21's Progress Notes dated, 11/11/2023 indicated, the SSD met with Resident 21 to follow-up on Advance Directive information.
During an interview with the SSD on 11/11/2023 at 4:45 p.m., the SSD stated she was not aware of Resident 21's request on more information regarding Advance Directive. The SSD stated she did not follow-up on Resident 21's request timely which is a residents' rights.
C. A review of Resident 28's admission Record indicated Resident 28 was admitted to the facility on [DATE], with diagnoses including intervertebral disc degeneration (when the spinal disks wear down), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest).
A review of Resident 28's MDS dated [DATE], indicated Resident 28's cognitive skills for daily decision-making were severely impaired and required maximal assistance from staff for ADLs (oral hygiene, lower body dressing, sit to lying and to stand and walking 10 feet).
A Review of Resident 28's Advance Directive Acknowledgement form, dated 10/14/2023 indicated, Resident 28's responsible party signed and indicated, I have executed an Advance Directive, and a copy has been requested.
A review of Resident 28's electronic and hard copy medical chart on 11/11/2023, indicated no Advance Directive on file for Resident 28.
A review of Resident 28's Progress Notes dated 11/11/2023 at 11:40 a.m., indicated, that SSD placed a call (telephone) to patient's (responsible party) to follow up on request for a copy of Advance Directive.
During an interview with the SSD on 11/11/2023 at 4:45 p.m., the SSD stated she was not aware of Resident 28's Advance Directive Acknowledgement Form dated 10/14/2023 that Resident 28 had an Advanced Directive. The SSD stated she did not follow-up on the copy of the Advance Directive timely for Resident 28 and the facility did not know what Resident 28 and responsible party's wishes were in the event that Resident 28 could no longer make decisions.
D. A review of Resident 36's admission Record indicated resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, end stage renal disease (ESRD - a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), and congestive heart failure (a condition in which the heart does not pump blood as well as it should).
A review of Resident 36's MDS dated [DATE], indicated Resident 36's cognitive skills for daily decision-making were moderately impaired and required moderate assistance from staff for ADLs- oral hygiene, toileting, shower/bathing, lower body dressing.
A Review of Resident 36's Advance Directive Acknowledgement form, dated 10/28/2023 indicated, Resident 26's signed and indicated, I have executed an Advance Directive, and a copy has been requested.
A review of Resident 36's electronic and hard copy medical chart on 11/11/2023, indicated no Advance Directive on file.
A review of Resident 36's Progress Notes dated, 11/11/2023 at 11:37 a.m., indicated the SSD placed a call to Resident 36's (responsible party) to follow up on a copy of the Advance Directive.
During an interview with the SSD on 11/11/2023 at 4:45 p.m., the SSD stated, she was not aware of Resident 36's Advance Directive Acknowledgement Form dated 10/28/2023 that Resident 36 had an Advanced Directive. The SSD stated she did not follow-up on the copy of the Advance Directive timely for Resident 36 and the facility did not know what Resident 36's wishes were in the event that Resident 36 can no longer make decisions.
D. A review of Resident 29's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of prostate (prostate cancer - a disease in which malignant (cancer) cells form in the tissues of the prostate), intervertebral disc degeneration, and spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine).
A review of Resident 29's MDS dated [DATE], indicated Resident 29's cognitive skills for daily decision-making were severely impaired and required moderate assistance from staff for ADLs- oral hygiene, toileting, shower/bathing, upper body dressing and personal hygiene.
A Review of Resident 29's Advance Directive Acknowledgement form, dated 10/17/2023 indicated, Resident 29's responsible party signed and indicated, I have executed an Advance Directive, and a copy has been requested.
A review of Resident 29's electronic and hard copy medical chart on 11/11/2023, indicated no Advance Directive on file.
A review of Resident 29's Progress Notes dated, 11/11/2023 at 11:23 a.m., indicated, the SSD placed a call to patient's (responsible party) to follow up on request of Advance Directive.
During an interview with the SSD on 11/11/2023 at 4:45 p.m., the SSD stated she was not aware of Resident 29's Advance Directive Acknowledgement Form dated 10/16/2023 that Resident 29 had an Advanced Directive. The SSD stated she did not follow-up on the copy of the Advance Directive timely for Resident 29 and that the facility did not know what Resident 29 and responsible party's wishes were in the event that Resident 29 could no longer make decisions.
A review of the facility's P&P titled, Advance Directives, revised 1/2023 indicated, Advance directives will be respected in accordance with state law and facility policy . upon admission, the resident will be provided with written information concerning the right to refuse of accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . prior to or upon admission or a resident, the social services 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 .
Based on interview and record review, the facility failed to, for eight of 22 sampled residents (Resident 11, 21, 28, 29, 36, 126, 127 and 227),:
1. Inform or offer advanced directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) information,
2. Maintain a current copy of resident's advance directive in resident's clinical record
3. Followed up and provided additional information on advanced directive upon request.
These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Residents 11, 21, 28, 29, 36, 126, 127 and 227.
Findings:
A. During a review of Resident 127's admission Record, indicated the facility admitted Resident 127 on 11/25/2022 with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) and obesity (a disorder involving excessive body fat that increases the risk of health problems).
During a review of Resident 127's Minimum Data Set (MDS- a standadrdizedassessment and care screening tool) dated 10/23/2023, indicated Resident 127's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making was intact. The MDS indicated Resident 127 required moderate to maximal staff assistance with activities of daily living (ADL).
During a review of Resident 127's Advance Directive Acknowledgement form, dated 11/25/2022, indicated Resident 127's representative signed the adavnced drective form and requested for additional information regarding advance directive.
During a review of Resident 127's Social Service Assessment, dated 8/8/2023, the assessment indicated no advance directive, and no documented that a follow up provided to Resident 127's representative regarding the requested additional information on advance directive.
During a concurrent interview and record review with the Social Serviced Director (SSD) on 11/12/2023 at 10:29 a.m., Resident 127's advanced directive was reviewed. The SSD also stated following up and providing advance directive information when requested by the resident or resident's family and documenting on the resident's medical record was important.
During a review of Resident 126's admission Record, indicated the facility admitted Resident 126 on 10/26/2023 with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue).
During a review of Resident 126's MDS, dated [DATE], indicated Resident 126's cognitive skill for daily decision-making was intact and moderate assistance with staff for ADLs.
During a review of Resident 126's Advance Directive Acknowledgement form, dated 10/26/2023, form indicated Resident 126's representative signed that advance directive was not executed; no other information if Resident 126's representative would like to receive additional information and/or refused any additional information regarding advance directive.
During a review of Resident 126's Social Service Assessment, dated 11/3/2023, the assessment indicated no advance directive, and no documented evidence that follow up was provided to Resident 126's representative if additional information regarding advance directive was needed.
During a concurrent interview and record review with the SSD on 11/12/2023 at 10:29 a.m., the SSD stated upon a resident's admission, nursing should complete advance directive acknowledgment form and social service department would follow up on any needed information. The SSD also stated following up and providing advance directive information when requested by the resident or resident's family and documenting on the resident's medical record was important.
A review of the facility's P&P titled, Advance Directives, revised on January 2023 indicated, Advance directives will be respected in accordance with state law and facility policy . upon admission, the resident will be provided with written information concerning the right to refuse of accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . prior to or upon admission or a resident, the social services 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 .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** D. A review of Resident 229's admission record indicated Resident 229 was admitted to the facility on [DATE] with diagnoses incl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** D. A review of Resident 229's admission record indicated Resident 229 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease with heart failure (refers to heart problems . Without appropriate blood pressure control, the heart can weaken over time and heart failure may develop) malignant neoplasm of prostate (Prostate cancer is cancer that occurs in the prostate. The prostate is a small walnut-shaped gland in males that produces the seminal fluid), and encephalopathy (any disease that affects the whole brain and alters its structure or how it works and causes changes in mental function).
A review of Resident 229's history and physical (the most formal and complete assessment of the patient and the problem. Physicians' documentation are produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending) dated 10/5/2023 indicated, Resident 229 had the capacity to understand and make decisions.
During an observation of Resident 229 on 11/10/2023 at 12:13 p.m., bilateral side rails were elevated.
A review of the physician's order with an effective date of 11/12/2023, indicated ¼ side rails up while in bed as enabler. Another order with the same effective date indicated, ¼ side rails up while in bed used for safe turning and repositioning.
During a concurrent interview and record review of Resident 229's orders on 11/12/23 5:15 p.m., RN 3 stated 1/4 is having one side rail up instead of two. She stated that having more side rails elevated would constitute a restraint (a measure or condition that keeps someone or something under control or within limits decisions are made within the financial restraints of the budget).
A review of the facility's P & P titled Use of Side Rails, revised January 2023 indicated, the purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. It indicated some general guidelines which included:
1. Side rails are considered a restraint when they are used to limit the. resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.)
2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents.
3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's:
a. Bed mobility;
b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet;
c. Risk of entrapment from the use of side rails; and
d. That the bed's dimensions are appropriate for the resident's size and weight.
Based on observation, interview, and record review, the facility failed to ensure that 10 of 10 sampled residents (Residents 6, 28, 38, 229, 7, 16, 27, 52, 57, and 127) were free from physical restraint by
a. failing to ensure the use of side rails (SR) are properly assessed in the Minimum Data Set (MDS - a standardized assessment and care-screening tool).
b. failing to ensure the physician's order for one fourth (1/4) side rails (SR) up as enablers for mobility were applied.
These deficient practices had the potential to result in entrapment and injury and residents not being treated with respect and dignity with the use of restraints.
Findings:
A. A review of Resident 6's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 6' s MDS dated [DATE], indicated Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required maximal to dependence from staff for activities of daily living (ADLs- oral hygiene, toileting, shower/bathing, personal hygiene). The MDS also indicated, Resident 6 is on physical restraints using bed rails daily.
A review of Resident 6's Physician's Order Summary Report, dated 11/10/2023 indicated, 1/4 SR (side rail) up while in bed as enabler for mobility and ¼ SR up while in bed for safe turning and repositioning.
A review of Resident 6's Safety Device/Mobility Device assessment dated [DATE] indicated, Resident 6 was observed to be able to use side rail for bed mobility with recommendations to use both sides, ¼ side rails for mobility device.
A review of Resident 6's care plan for ¼ bed SR as enabler to assist with bed mobility, initiated on 10/29/2023 had a goal of will continue to utilize the ¼ SR to assist with turning, repositioning, or transfer.
During an observation with Resident 6 on 11/10/2023 at 11:36 a.m., Resident was observed with bilateral upper siderails up.
B. A review of Resident 28's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including intervertebral disc degeneration (when the spinal disks wear down), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest).
A review of Resident 28's MDS dated [DATE], indicated Resident 28's cognitive skills for daily decision-making were severely impaired and required maximal assistance from staff for ADLs- oral hygiene, lower body dressing, sit to lying and to stand and walking 10 feet. The MDS also indicated, Resident 28 is on physical restraints using bed rails daily.
A review of Resident 28's Physician's Order Summary Report, dated 10/13/2023 indicated, 1/4 SR up while in bed as enabler for mobility and ¼ SR up while in bed for safe turning and repositioning.
A review of Resident 28's Safety Device/Mobility Device Assessment, dated 10/13/2023 indicated, Resident 28 was observed to be able to use side rail for bed mobility with recommendations to use both sides, ¼ side rails for mobility device.
A review of Resident 28's care plan for ¼ bed SR as enabler to assist with bed mobility, initiated on 10/13/2023 had a goal of will continue to utilize the ¼ SR to assist with turning, repositioning, or transfer.
During an observation with Resident 6 on 11/10/2023 at 11:12 a.m., Resident 28 was observed with bilateral upper siderails up.
C. A review of Resident 38's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) metabolic 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) and primary osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down).
A review of Resident 38's MDS dated [DATE], indicated Resident 38's skills for daily decision-making were moderately impaired and required maximal assistance to dependent from staff for ADLs- roll left and right, sit to lying, lying to sitting and car transfer. The MDS also indicated that Resident 38 is on physical restraints using bed rails daily.
A review of Resident 38's Physician's Order Summary Report, dated 10/23/2023 indicated, 1/4 SR up while in bed as enabler for mobility and ¼ SR up while in bed for safe turning and repositioning.
A review of Resident 38's Safety Device/Mobility Device Assessment, dated 10/23/2023 indicated, Resident 38 was observed to be able to use side rail for bed mobility with recommendations to use both sides, ¼ side rails for mobility device.
A review of Resident 38's care plan for ¼ bed SR as enabler to assist with bed mobility, initiated on 10/23/2023 had a goal of will continue to utilize the ¼ SR to assist with turning, repositioning, or transfer.
During an observation with Resident 38 on 11/10/2023 at 11:28 a.m., Resident 38 was observed with bilateral upper siderails up.
During an interview with Director of Nursing (DON), on 11/12/2023 at 4:51 p.m., DON stated, they utilize bed rails up as enablers for mobility with physician's order of ¼ SR up. DON stated, the nurse's safety device/mobility device assessment does not correlate together with physician's order as indicated ¼ SR up, and the safety device/mobility device assessment indicated both sides, bed SR up. DON stated, ¼ side rails is not the same as both sides side rails up. DON stated, the facility did not follow physician's order.
A review of the facility's policy and procedures (P&P) titled, Use of Side Rails, revised January 2023 indicated, The purposes of these guidelines are to ensure the sage use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents.
During a review of Resident 7's admission Record, indicated the facility originally admitted Resident 7 on 9/3/2023 and was re-admitted on [DATE] with diagnoses including fracture of bilateral humerus (a break, crack or crush injury of the bone in both arms), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body).
During a review of Resident 7's Safety Device/Mobility Device Assessment, dated 9/3/2023, assessment indicated Resident 7was recommended by the interdisciplinary team (IDT) to have both sides ¼ side rails for mobility device, improve function, improve posture, grab bar, and repositioning.
During a review of Resident 7's Order Summary Report, dated 9/15/2023. The Order Summary Report indicated Resident 7 had an order for one fourth (1/4) side rails (SR) up while in bed as enabler for mobility and ¼ SR up while in bed for safe turning and repositioning.
During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skill for daily decision-making was intact and with one-person physical assistance for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene).
During an observation on 11/10/2023 at 12:05 p.m., Resident 7 was observed laying in bed with bilateral upper SR up.
During an observation on 11/11/2023 at 9:30 a.m., Resident 7 was observed laying in bed with bilateral upper SR up.
During an interview with Registered Nurse 3 (RN 3) on 11/12/2023 at 4:57 p.m., RN 3 stated that the SR order should be ordered as bilateral or both ¼ SR, instead of only ¼ SR. RN 3 stated and validated that ¼ SR order means that resident only needs 1 side rail up, either on left or right of upper or bottom SR. RN 3 also verified that all residents that has an order for SR when in bed as either enabler or turn/repositioning needs the bilateral upper SR up for safety.
During a review of Resident 16's admission Record, indicated the facility admitted Resident 16 on 9/13/2023 with diagnoses including osteoporosis (a condition in which bones become weak and brittle), Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease).
During a review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/5/2023, the MDS indicated Resident 16's cognitive skill for daily decision-making was severely impaired and with moderate to maximal assistance for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene). MDS also indicated Resident 16 was using bed rail restraints daily.
During a review of Resident 16's Order Summary Report, dated 9/13/2023. The Order Summary Report indicated Resident 16 had an order for one fourth (1/4) side rails (SR) up while in bed as enabler for mobility and ¼ SR up while in bed for safe turning and repositioning.
During an observation on 11/10/2023 at 11:40 a.m., Resident 16 was observed laying in bed with bilateral upper SR up.
During an observation on 11/11/2023 at 9:23 a.m., Resident 16 was observed laying in bed with bilateral upper SR up.
During an interview with RN 3 on 11/12/2023 at 4:57 p.m., RN 3 stated that the SR order should be ordered as bilateral or both ¼ SR, instead of only ¼ SR. RN 3 stated and validated that ¼ SR order means that resident only needs 1 side rail up, either on left or right of upper or bottom SR. RN 3 also verified that all residents that has an order for SR when in bed as either enabler or turn/repositioning needs the bilateral upper SR up for safety.
During a review of Resident 27's admission Record, indicated the facility originally admitted Resident 27 on 11/29/2022 and was re-admitted on [DATE] with diagnoses including COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person), hypertension (HTN - elevated blood pressure) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease).
During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27's cognitive skill for daily decision-making was severely impaired and with maximal assistance for ADLs.
During a review of Resident 27's Order Summary Report, dated 10/31/2023. The Order Summary Report indicated Resident 27 had an order for one fourth (1/4) side rails (SR) up while in bed as enabler for mobility and ¼ SR up while in bed for safe turning and repositioning.
During a review of Resident 27's Safety Device/Mobility Device Assessment, dated 10/31/2023, assessment indicated Resident 27 was recommended by the IDT to have both sides ¼ side rails for mobility device, improve function, improve posture, grab bar, and repositioning.
During an observation on 11/10/2023 at 12:01 p.m., Resident 27 was observed laying in bed with bilateral upper SR up.
During an observation on 11/11/2023 at 9:24 a.m., Resident 27 was observed laying in bed with bilateral upper SR up.
During an interview with RN 3 on 11/12/2023 at 4:57 p.m., RN 3 stated that the SR order should be ordered as bilateral or both ¼ SR, instead of only ¼ SR. RN 3 stated and validated that ¼ SR order means that resident only needs 1 side rail up, either on left or right of upper or bottom SR. RN 3 also verified that all residents that has an order for SR when in bed as either enabler or turn/repositioning needs the bilateral upper SR up for safety.
During a review of Resident 52's admission Record, indicated the facility admitted Resident 52 on 10/27/2023 with diagnoses including neoplasm (a new and abnormal growth of tissues) in the bladder and vaginal area and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing).
During a review of Resident 52's Order Summary Report, dated 10/27/2023. The Order Summary Report indicated Resident 52 had an order for 1/4 SR up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning.
During a review of Resident 52's Safety Device/Mobility Device Assessment, dated 10/27/2023, assessment indicated Resident 52 was recommended by the interdisciplinary team (IDT) to have both sides ¼ side rails for mobility device, improve function, improve posture, grab bar, and repositioning.
During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52's cognitive skill for daily decision-making was intact and with some supervision with staff for ADLs. MDS also indicated Resident 16 was using bed rail restraints daily.
During an observation on 11/10/2023 at 12:05 p.m., Resident 52 was observed laying in bed with bilateral upper SR up.
During an observation on 11/11/2023 at 9:30 a.m., Resident 52 was observed laying in bed with bilateral upper SR up.
During an interview with RN 3 on 11/12/2023 at 4:57 p.m., RN 3 stated that the SR order should be ordered as bilateral or both ¼ SR, instead of only ¼ SR. RN 3 stated and validated that ¼ SR order means that resident only needs 1 side rail up, either on left or right of upper or bottom SR. RN 3 also verified that all residents that has an order for SR when in bed as either enabler or turn/repositioning needs the bilateral upper SR up for safety.
During a review of Resident 57's admission Record, indicated the facility admitted Resident 57 on 10/23/2023 with diagnoses including osteoporosis, hemiplegia and hemiparesis.
During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57's cognitive skill for daily decision-making was moderately impaired and with moderate assistance with staff for ADLs. MDS also indicated Resident 57 was using bed rail restraints daily.
During a review of Resident 57's Order Summary Report, dated 10/23/2023. The Order Summary Report indicated Resident 57 had an order for 1/4 SR up while in bed for safe turning and repositioning.
During a review of Resident 57's Safety Device/Mobility Device Assessment, dated 11/11/2023, assessment indicated Resident 57 was recommended by the IDT to have both sides ¼ SR for mobility device, improve function, improve posture, grab bar, and repositioning.
During an observation on 11/10/2023 at 12:50 p.m., Resident 57 was observed laying in bed with bilateral upper SR up.
During an observation on 11/11/2023 at 9:24 a.m., Resident 57 was observed laying in bed with bilateral upper SR up.
During an interview with RN 3 on 11/12/2023 at 4:57 p.m., RN 3 stated that the SR order should be ordered as bilateral or both ¼ SR, instead of only ¼ SR. RN 3 stated and validated that ¼ SR order means that resident only needs 1 side rail up, either on left or right of upper or bottom SR. RN 3 also verified that all residents that has an order for SR when in bed as either enabler or turn/repositioning needs the bilateral upper SR up for safety.
During a review of Resident 127's admission Record, indicated the facility admitted Resident 127 on 11/25/2022 with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) and obesity (a disorder involving excessive body fat that increases the risk of health problems).
During a review of Resident 127's MDS, dated [DATE], the MDS indicated Resident 127's cognitive skill for daily decision-making was intact and moderate to maximal assistance with staff for ADLs.
During a review of Resident 127's Order Summary Report, dated 11/25/2023. The Order Summary Report indicated Resident 127 had an order for 1/4 SR up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning.
During a review of Resident 127's Safety Device/Mobility Device Assessment, dated 10/18/2023, assessment indicated Resident 127 was recommended by the IDT to have both sides ¼ SR for mobility device, improve function, improve posture, grab bar, and repositioning.
During an observation on 11/10/2023 at 12:53 p.m., Resident 127 was observed laying in bed with bilateral upper SR up.
During an observation on 11/11/2023 at 9:26 a.m., Resident 127 was observed laying in bed with bilateral upper SR up.
During an interview with RN 3 on 11/12/2023 at 4:57 p.m., RN 3 stated that the SR order should be ordered as bilateral or both ¼ SR, instead of only ¼ SR. RN 3 stated and validated that ¼ SR order means that resident only needs 1 side rail up, either on left or right of upper or bottom SR. RN 3 also verified that all residents that has an order for SR when in bed as either enabler or turn/repositioning needs the bilateral upper SR up for safety.
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 that a preadmission screening assessment was done for a resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a preadmission screening assessment was done for a resident who was diagnosed with a mental illness prior to admission in the facility for one of one sampled resident (Resident 21).
This deficient practice had the potential for not receiving the necessary and appropriate psychiatric (relating to mental illness or its treatment) level of treatment and evaluation in the facility.
Cross Reference: F645.
Findings:
A review of Resident 21's admission Record indicated Resident 21 was admitted to the facility on [DATE], with diagnoses including chronic hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and radiculopathy (injury or damage to nerve roots in the area where they leave the spine).
A review of Resident 21's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 9/13/2023, indicated Resident 21's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired and required extensive assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use).
A review of Resident 21's Preadmission Screening and Resident Review (PASARR) indicated, the PASARR screening was completed on 11/11/2023.
During an interview with the Director of Nursing (DON) on 11/12/2023 at 3:57 p.m., DON stated PASARR was to be completed within 24 hours of admission/re-admission or prior to admission. The DON stated Resident 21's PASARR screening was not completed timely.
A review of the facility's policy and procedures (P&P) titled, Preadmission Screening & Resident Review (PASARR), revised on May 2023 indicated, PASARR requires that all applicants . to be evaluated for a serious mental disorder and/or intellectual disability . the facility will obtain/complete a Preadmission Screening and Resident Review timely . pre-admit and date of PASARR should be the same day of admit as stated above. DON or Registered Nurse (RN) will complete the PASARR before admitting a resident from home or senior living facilities or on admission date.
D. During a review of Resident 16's admission Record, indicated the facility admitted Resident 16 on 9/13/2023 with diagnoses including osteoporosis (a condition in which bones become weak and brittle), Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function) and dementia.
During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16's cognitive skill for daily decision-making was severely impaired and with moderate to maximal assistance for ADLs- bed mobility, dressing, toilet use, and personal hygiene. MDS also indicated Resident 16 was using bed rail restraints daily.
During a review of Resident 16's Order Summary Report, dated 9/13/2023. The Order Summary Report indicated Resident 16 had an order for 1/4 SR up while in bed as enabler for mobility and ¼ SR up while in bed for safe turning and repositioning.
During an interview with the MDSN 2 on 11/11/2023 at 3:30 p.m., MDSN 2 stated and verified that there were no residents in the facility currently using some type of restraint. MDSN 2 stated that since the ¼ SR are being used as enabler and for safe turning and repositioning for residents, it should not be triggered under the restraints and alarms in the MDS.
A review of facility's policy and procedure (P&P), titled, Resident Assessment Instrument, revised 9/2023, P&P indicated that facility will complete a comprehensive assessment that will help staff to plan care that allows the resident to reach his/her highest practicable level of functioning.
A review of facility's P&P, titled, Use of Side Rails, revised on 9/2023, P&P indicated that facility would ensure safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. P&P also indicated that physical restraints are defined by the Centers for Medicate and Medicaid Services (CMS) as any manual method or physical device or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
E. During a review of Resident 52's admission Record, indicated the facility admitted Resident 57 on 10/27/2023 with diagnoses including neoplasm (a new and abnormal growth of tissues) in the bladder and vaginal area and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing).
During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52's cognitive skill for daily decision-making was intact and with some supervision with staff for ADLs. MDS also indicated Resident 16 was using bed rail restraints daily.
During a review of Resident 52's Order Summary Report, dated 10/27/2023. The Order Summary Report indicated Resident 52 had an order for 1/4 SR up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning.
During a review of Resident 52's Safety Device/Mobility Device Assessment, dated 10/27/2023, assessment indicated Resident 52 was recommended by the interdisciplinary team (IDT) to have both sides ¼ side rails for mobility device, improve function, improve posture, grab bar, and repositioning.
During an interview with the MDSN 2 on 11/11/2023 at 3:30 p.m., MDSN 2 stated and verified that there were no residents in the facility currently using some type of restraint. MDSN 2 stated that since the ¼ SR are being used as enabler and for safe turning and repositioning for residents, it should not be triggered under the restraints and alarms in the MDS.
A review of facility's P&P, titled, Resident Assessment Instrument, revised 9/2023, P&P indicated that facility will complete a comprehensive assessment that will help staff to plan care that allows the resident to reach his/her highest practicable level of functioning.
A review of facility's P&P, titled, Use of Side Rails, revised on 9/2023, P&P indicated that facility would ensure safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. P&P also indicated that physical restraints are defined by the CMS as any manual method or physical device or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
F. During a review of Resident 57's admission Record, indicated the facility admitted Resident 57 on 10/23/2023 with diagnoses including osteoporosis, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body).
During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57's cognitive skill for daily decision-making was moderately impaired and with moderate assistance with staff for ADLs. MDS also indicated Resident 57 was using bed rail restraints daily.
During a review of Resident 57's Order Summary Report, dated 10/23/2023. The Order Summary Report indicated Resident 57 had an order for 1/4 SR up while in bed for safe turning and repositioning.
During a review of Resident 57's Safety Device/Mobility Device Assessment, dated 11/11/2023, assessment indicated Resident 57 was recommended by the IDT to have both sides ¼ SR for mobility device, improve function, improve posture, grab bar, and repositioning.
During an interview with the MDSN 2 on 11/11/2023 at 3:30 p.m., MDSN 2 stated and verified that there were no residents in the facility currently using some type of restraint. MDSN 2 stated that since the ¼ SR are being used as enabler and for safe turning and repositioning for residents, it should not be triggered under the restraints and alarms in the MDS.
A review of facility's P&P, titled, Resident Assessment Instrument, revised 9/2023, P&P indicated that facility will complete a comprehensive assessment that will help staff to plan care that allows the resident to reach his/her highest practicable level of functioning.
A review of facility's P&P, titled, Use of Side Rails, revised on 9/2023, P&P indicated that facility would ensure safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. P&P also indicated that physical restraints are defined by the CMS as any manual method or physical device or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
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 safe provision of pharmaceutical services by fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to:
1. Ensure Resident 6's self-administered medication was properly stored.
2. Ensure one of two medication storage refrigerator (refrigerator 1's) temperatures were within the acceptable range.
3. Ensure proper labeling of an opened foil pack of DuoNeb (medication to treat symptoms associated with lung disease) for Resident 6.
4. Ensure ophthalmic (eye) medications were refrigerated per pharmacy for Resident 175 and 232.
These deficient practices had the potential to compromise the safety and effectiveness of medications, resulting in possible medication errors.
Findings:
1. A review of Resident 6's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), acute respiratory failure (a serious condition that makes it difficult to breathe on your own), and type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 11/2/2023, indicated Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact, Resident 6 required maximum assistance to dependence from staff for activities of daily living (ADLs- oral hygiene, toileting, shower/bathing, personal hygiene).
A review of Resident 6's Physician Order Summary Report, dated 11/10/2023 indicated, Fluticasone propionate suspension (a nasal spray used to relieve symptoms of nonallergic rhinitis [reactions that causes nasal congestion] such as sneezing and runny or stuffy nose) 50 microgram/actuation (mcg/act) - 1 spray in each nostril as needed for allergic rhinitis unsupervised self-administration, okay to have at bedside, patient may self-administer.
During the facility tour on 11/10/2023 at 4:25 p.m., Resident 6 was not in his room. However. fluticasone nasal spray was observed stored on top of Resident 6's bed, accessible to others.
During an interview with Registered Nurse 1 (RN 1) on 11/10/2023 at 4:35 p.m. in Resident 6's room, RN 1 stated Resident 6's fluticasone nasal spray medication was on top Resident 6's bed and it(medication) should be stored securely and not accessible by others. RN 1 further stated, if the medication at bedside is stored unsecured, this puts other residents and visitors at risk of taking the medications unattended without knowing what it is for.
A review of the facility's policy and procedure (P&P) titled, Self-Administration of Medications, revised February 2023 indicated, Self-administered medications are stored in a safe and secure place, which is not accessible by other residents.
2. During a concurrent interview and observation of Medication room [ROOM NUMBER] with RN 2 on 11/12/2023 at 10:18 a.m., there was one refrigerator inside the medication room, RN 2 stated the refrigerator contained IV (intravenous) medications for the residents in the facility.
A review of the IV refrigerator temperature log for the month of October indicated the following:
i.
10/12/2023 - temperature of 32 degrees Fahrenheit (F)
ii.
10/12/2023 - 32 degrees F
iii.
10/13/2023 - 32 degrees F
iv.
10/14/2023 - 32 degrees F
v.
10/15/2023 - 32 degrees F
vi.
10/16/2023 - 34 degrees F
vii.
10/17/2023 - 34 degrees F
During an interview with RN 2 on 11/12/2023 at 10:30 a.m., RN 2 stated, the temperatures of the refrigerator are checked in the morning shift and the night shift, and the acceptable temperature range was between 36 degrees F - 46 degrees F. RN 2 stated and confirmed, the IV refrigerator temperature for the month of October was out of the acceptable range. RN 2 stated, this might affect the medications being stored in the refrigerator.
During an interview with Director of Nursing (DON) on 11/12/2023 at 4:51 p.m., the DON stated, when the medications refrigerator temperature is out of within the range, staffs should contact the maintenance department to assess the equipment. The DON stated, there was no documentation that the staffs had contacted the maintenance regarding the IV refrigerator when the temperatures were out of range.
A review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, updated on August 2023 indicated, medication requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring.
3. A review of Resident 6's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including CKD, acute respiratory failure, and type II DM.
A review of Resident 6's MDS, dated [DATE], indicated Resident 6's cognitive skills for daily decision-making were intact and required maximum of assistance to dependence from staff for ADLs.
A review of Resident 6's Physician Order Summary Report, dated 10/29/2023 indicated, DuoNeb 3-millimeter (ml) inhale (breathe in) every four hours as needed for shortness of breath or wheezing (high pitched sound when inhaling).
During a concurrent observation and interview with Licensed Vocational Nurse 6 (LVN 6) on 11/12/2023 at 11:46 a.m., Resident 6's undated opened foil pack of DuoNeb was observed in Medication Cart 2. LVN 6 stated that foil pack should have a date when it was opened.
A review of the facility's P&P, titled, Administering Medications, revised on 4/2023, the P&P indicated that when opening a container, the date opened is recorded.
A review of DuoNeb's manufacturer's policy, undated, indicated that once open/removed from the foil pouch, should be used within a week.
4a. A review of Resident 175's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including neoplasm (a new and abnormal growth of tissues) of digestive organs (includes mouth, throat, esophagus, stomach, small intestine, large intestine, rectum and anus), and glaucoma (eye condition that can cause blindness).
A review of Resident 175's Physician Order Summary Report, dated 10/20/2023 indicated, travoprost hydrochloride (eye drop used to treat increased pressure in the eye) 0.004 percent (%) to instill one drop in both eyes at bedtime for glaucoma.
During a concurrent observation and interview with LVN 6 on 11/12/2023 at 11:57 a.m., Resident 175's travoprost eye solution container with a sticker indicated refrigerate was observed inside Medication Cart 2. LVN 6 stated that medication should be inside the refrigerator per pharmacy policy.
A review of the facility's P&P, titled, Storage of Medication, revised on 1/2023, the P&P indicated that the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The P&P also indicated that medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location.
4b. A review of Resident 232's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including urinary tract infection (UTI-infection in the urinary system [kidneys, bladder, or urethra]), and glaucoma.
A review of the Resident 232's MDS, dated [DATE], indicated Resident 232's cognitive skills for daily decision-making were intact and the resident was dependent on staff for ADLs.
A review of Resident 232's Physician Order Summary Report, dated 11/9/2023 indicated, latanoprost 0.005 % (eye drop used to treat increased pressure in the eye) to instill one drop in both eyes at bedtime for glaucoma.
During a concurrent observation and interview with LVN 6 on 11/12/2023 at 11:57 a.m., Resident 232's latanoprost eye solution container with a sticker indicated refrigerate was observed inside Medication Cart 2. LVN 6 stated that medication should be stored inside the refrigerator per pharmacy policy.
A review of the facility's P&P, titled, Storage of Medication, revised on 1/2023, the P&P indicated that the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The P&P also indicated that medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that one of one sampled emergency crash cart (set of trays, drawers or shelves on wheels used in a medical facility fo...
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Based on observation, interview, and record review, the facility failed to ensure that one of one sampled emergency crash cart (set of trays, drawers or shelves on wheels used in a medical facility for transporting and dispensing emergency equipment at site for life support protocols):
1. Ensure crash cart was readily available; Registered Nurse 1 (RN 1) did not know the code and/or which key to use when opening the emergency crash cart.
2. Ensure crash cart log was checked and updated on a daily basis and as needed.
These deficient practices had the potential of delayed provisions of emergency care for all the current residents who wishes to have full treatment in a life-threatening situation.
Findings:
During a concurrent observation and interview with RN 1 on 10/24/2023 at 10:10 a.m., observed missing crash cart checks on the following dates:
9/22/2023; 9/23/2023; 9/29/2023; 9/30/2023; 10/6/2023; 10/7/2023; 10/20/2023; 10/21/2023; 10/22/2023; 10/23/2023; and 10/24/2023.
RN 1 stated and verified missing check. RN 1 was unable to open the crash cart and stated not knowing the code and or was not aware of the key. RN 1 stated that crash cart must be checked daily and as needed and added importance of knowing the code and or the key in case of emergency.
During an interview with the Director of Nursing (DON) on 10/24/2023 at 12:40 p.m., DON stated that all staff especially licensed nurses should know the code/ and or the key to the crash cart. DON also stated importance of checking the crash cart daily and as needed to make sure all supplies are up to date and re-stocked in case of emergency.
A review of facility ' s policy and procedures (P&P) titled, Policy for Emergency Cart, reviewed on 10/2023, P&P indicated, facility to organize and maintain the emergency cart to ensure adequate needed equipment during an emergency procedure. P&P also indicated that that all nurses should be familiar with each cart contents and locations; and new employees will be oriented to all emergency bags/kits and training programs will be provided to maintain competence in emergency response.
Sept 2023
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that ea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) booster vaccination was consented properly and complete, educated upon refusals with documentation when offered to one of eight sampled residents (Resident 5).
This failure had the potential to result in Resident 5's COVID-19 infection.
Findings:
During a review of Resident 5's admission Record, indicated that Resident 5 was admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack), hypertension (HTN - elevated blood pressure) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease).
During a review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/19/2023, the MDS indicated Resident 5 had a moderately impaired cognition (thought processes) for daily decision making and with one person assist from staff for activities of daily living (ADLs-bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene).
During a concurrent interview and record review on 9/3/2023 at 1:47 p.m., with the Infection Preventionist Nurse (IPN), Resident 5's COVID-19 Vaccine Booster Consent Form (CVCF) and progress notes (PN), was reviewed. Resident 5's CVCF and PN indicated missing check sign on both consenting and refusing COVID-19 vaccination. PN also indicated missing documentation on the education and refusal of COVID-19. IPN stated and verified missing information and stated importance of properly completing consents and documentation of education and refusals per facility policy.
During a review of the facility's policy and procedures (P&P) titled, Vaccination of Residents, dated 10/2019, the P&P indicated, If vaccines are refused, the refusal shall be documented in the resident's medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1b. A review of Resident 2's admission record indicated the resident was admitted on [DATE] with diagnosis including osteomyelit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1b. A review of Resident 2's admission record indicated the resident was admitted on [DATE] with diagnosis including osteomyelitis, discitis (an inflammation of the vertebral disk space often related to infection), and spinal stenosis (this condition narrows the amount of space within the spine).
A review of Resident 2's MDS dated [DATE], indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact.
A review of Resident 2's Care plan, initiated 8/19/2023, indicated Resident 2's needs IV therapy due to bacteremia (presence of bacteria in the bloodstream) infection with IV order of Cefriaxone Sodium daily solution and had the potential for complications related to IV therapy. It also indicated that one of interventions were to change IV site, dressings, tubing, solution container per protocol.
A review of Resident 2's physician order, initiated 8/18/2023, indicated resident had an order to change PICC line dressing, remove dressing with alcohol swab, replace biopatch around the insertion site, secure with catheter stabilization device, cover with tegaderm every seven days for IV maintenance and as needed for soilage/displacement.
During a concurrent observation and interview on 9/2/2023 at 8:45 a.m. with Resident 2, observed right upper arm PICC line access, the transparent dressing has no label of date and time and was peeling off the edge and left upper arm midline (catheter inserted in the upper arm with the tip located just below the axilla) access, the transparent dressing has no label of date and time and was peeling off the edge. Resident 2 stated that he is getting IV antibiotic for infection and the dressing for both his IV access has not been changed since he got admitted .
During an interview with RN 1 on 9/2/2023 at 2:11 p.m., RN 1 stated that resident 2 is on IV antibiotic daily and she had not changed the dressing on his PICC line. RN 1 also stated that PICC line dressing should be changed every 7 days and as needed, mostly on Sundays. RN 1 further stated, she does not remember his midline dressing but they only use his PICC line for IV antibiotic.
During a concurrent interview and record review on 9/3/2023 at 12:32 p.m., with DON, Resident 2's skin assessment record and transfer record from General Acute Care Hospital 1 (GACH 1) were reviewed. DON stated that Resident 2 was admitted with a PICC line and Midline access but no assessment of his PICC line and Midline access upon admission was documented. DON stated that if the central line access were not assessed upon admission and dressings were not changed per physician's order and per policy, this put residents at risk of getting infection and complications from IV site.
2. During a review of Resident 5's admission Record, indicated that Resident 5 was admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack), hypertension (HTN - elevated blood pressure) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease).
During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had a moderately impaired cognition for daily decision making.
During a concurrent interview and record review on 9/3/2023 at 1:47 p.m., with the Infection Preventionist Nurse (IPN), Resident 5's COVID-19 Vaccine Booster Consent Form (CVCF), dated 9/3/2023, and Resident 5's care plan was reviewed. Resident 5's CVCF indicated refusal of COVID-19 vaccination and missing refusal of COVID-19 vaccination care plan. IPN stated and verified refusal of COVID-19 and missing refusal care plan. IPN also stated that care plan must be develop when a resident refuses any care or treatment.
A review of the facility's policy and procedures titled Care Plans, Comprehensive Person-Centered last revised date of 12/2016, 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 . each resident's comprehensive person-centered care plan will be consistent with the resident's right to participate in the development and implementation of his or her plan of care, including the right to: . received the services and/or items included in the plan of care.
Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for three of three sampled residents (Residents 1, 2 and 5) by failing to:
1. Implement a comprehensive and resident-centered care plan regarding Resident 1 and 2's peripherally inserted central catheter (PICC line-type of catheter that is placed in a large vein that allows to give medications intravenously [IV-given via vein]).
2. Develop and implement a resident-centered care plan when Resident 5 refused COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccination.
These deficient practices had the potential to fail during the delivery of necessary care and services to Residents 1, 2 and 5.
Findings:
1a. A review of Resident 1's admission record indicated the resident was admitted on [DATE] with diagnosis including osteomyelitis (infection of the bone), right hip stage 4 pressure ulcer (injury that breaks down the skin and underlying tissue) and Parkinson's disease (brain disorder that causes unintended or uncontrollable movements).
A review of Resident 1's Comprehensive Minimum Data Set (MDS-a standardized assessment and screening tool) dated 8/30/2023 indicated that Resident 1 had the capacity to understand and make decisions.
A review of Resident 1's Care plan dated 8/28/2023, indicated Resident 1 needed IV therapy due to osteomyelitis: with IV order of Cefriaxone Sodium (antibiotic) 40Mg/ML (Mg/ML-units of measures) and Vancomycin hydrochloride (antibiotic) IV solution and had the potential for complications related to IV therapy. It also indicated that one of interventions were to change IV site, dressings, tubing, solution container per protocol.
A review of Resident 1's physician order dated 8/26/2023, indicated resident had an order for change PICC line dressing, remove dressing with alcohol swab, replace biopatch (dressing that prevent infection in the insertion site) around the insertion site), secure with catheter stabilization device, cover with tegaderm (transparent medical dressing) every seven days for IV maintenance and as needed for soilage/displacement.
During a concurrent observation and interview on 9/2/2023 at 8:45 a.m. with Resident 1, right upper arm PICC line was observed with date 8/24/2023. Resident 1 stated that he is getting IV antibiotic for infection. Resident 1 stated that he does not remember when the PICC line dressing was last changed.
During an interview on 9/2/2023 at 2:06 p.m. with Registered Nurse 1 (RN 1) stated that resident 1 last IV dressing changed was on 8/24/2023. RN 1 also stated that PICC line dressing should be changed every 7 days and as needed.
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** B. A review of Resident 2's admission record indicated the resident was admitted on [DATE] with diagnosis including osteomyeliti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A review of Resident 2's admission record indicated the resident was admitted on [DATE] with diagnosis including osteomyelitis, discitis (an inflammation of the vertebral disk space often related to infection), and spinal stenosis (this condition narrows the amount of space within the spine).
A review of Resident 2's MDS dated [DATE], indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact.
A review of Resident 2's Care plan, initiated 8/19/2023, indicated Resident 2's needs IV therapy due to bacteremia (presence of bacteria in the bloodstream) infection with IV order of Cefriaxone Sodium daily solution and had the potential for complications related to IV therapy. It also indicated that one of interventions were to change IV site, dressings, tubing, solution container per protocol.
A review of Resident 2's physician order, initiated 8/18/2023, indicated resident had an order to change PICC line dressing, remove dressing with alcohol swab, replace biopatch around the insertion site, secure with catheter stabilization device, cover with tegaderm every seven days for IV maintenance and as needed for soilage/displacement.
During a concurrent observation and interview on 9/2/2023 at 8:45 a.m. with Resident 2, observed right upper arm PICC line access, the transparent dressing has no label of date and time and was peeling off the edge and left upper arm midline (catheter inserted in the upper arm with the tip located just below the axilla) access, the transparent dressing has no label of date and time and was peeling off the edge. Resident 2 stated that he is getting IV antibiotic for infection and the dressing for both his IV access has not been changed since he got admitted .
During an interview with RN 1 on 9/2/2023 at 2:11 p.m., RN 1 stated that resident 2 is on IV antibiotic daily and she had not changed the dressing on his PICC line. RN 1 also stated that PICC line dressing should be changed every 7 days and as needed, mostly on Sundays. RN 1 further stated, she does not remember his midline dressing but they only use his PICC line for IV antibiotic.
During a concurrent interview and record review on 9/3/2023 at 12:32 p.m., with DON, Resident 2's skin assessment record and transfer record from General Acute Care Hospital 1 (GACH 1) were reviewed. DON stated that Resident 2 was admitted with a PICC line and Midline access but no assessment of his PICC line and Midline access upon admission was documented. DON stated that if the central line access were not assessed upon admission and dressings were not changed per physician's order and per policy, this put residents at risk of getting infection and complications from IV site.
A review of the facility's policy and procedure (P&P) titled Central Venous Catheter Dressing Changes last revised date of 4/2016, indicated that the purpose of the procedure is to prevent catheter related infections that are associated with contaminated, loosened, soiled or wet dressing. It also indicated to change transparent semi-permeable membrane (TSM) dressings at least every five to seven days and as needed when wet, soiled or not intact).
A review of the facility's P&P titled, Midline Dressing Changes last revised date of 4/2016 indicated, the purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. The same P&P also indicated, change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way.
Based on observation, interview, and record review the facility failed to ensure two of four sampled residents (Residents 1 and 2) with Intravenous (IV-given via vein) catheter was provided safe care to prevent complications. Residents 1 and 2 had a Peripherally inserted central catheter (PICC line-type of catheter that is placed in a large vein that allows to give medications intravenously) line and the dressing was not changed per facility's policy.
This deficient practice had the potential to place Residents 1 and 2 at risk for developing complications such as inflammation of the vein and infection.
Findings:
a. A review of Resident 1's admission record indicated the resident was admitted on [DATE] with diagnosis including osteomyelitis (infection of the bone), right hip stage 4 pressure ulcer (injury that breaks down the skin and underlying tissue) and Parkinson's disease (brain disorder that causes unintended or uncontrollable movements).
A review of Resident 1's Comprehensive Minimum Data Set (MDS-a standardized assessment and screening tool) dated 8/30/2023 indicated that Resident 1 had the capacity to understand and make decisions.
A review of Resident 1's Care plan dated 8/28/2023, indicated Resident 1 needed IV therapy due to osteomyelitis: with IV order of Cefriaxone Sodium (antibiotic) 40Mg/ML (Mg/ML-units of measures) and Vancomycin hydrochloride (antibiotic) IV solution and had the potential for complications related to IV therapy. It also indicated that one of interventions were to change IV site, dressings, tubing, solution container per protocol.
A review of Resident 1's physician order dated 8/26/2023, indicated resident had an order for change PICC line dressing, remove dressing with alcohol swab, replace biopatch (dressing that prevent infection in the insertion site) around the insertion site), secure with catheter stabilization device, cover with tegaderm (transparent medical dressing) every seven days for IV maintenance and as needed for soilage/displacement.
During a concurrent observation and interview on 9/2/2023 at 8:45 a.m. with Resident 1, right upper arm PICC line was observed with date 8/24/2023. Resident 1 stated that he is getting IV antibiotic for infection. Resident 1 stated that he does not remember when the PICC line dressing was last changed.
During an interview on 9/2/2023 at 2:06 p.m. with Registered Nurse 1 (RN 1) stated that resident 1 last IV dressing changed was on 8/24/2023. RN 1 also stated that PICC line dressing should be changed every 7 days and as needed.
During a concurrent interview and record review on 9/3/2023 at 12:25 p.m. with Director of Nursing (DON), Resident 1's skin assessment record and medication administration record for month of August to September 2023 was reviewed. DON stated that Resident 1 did not have any assessment of his PICC line upon admission. DON also stated that there was no documentation on when the PICC line dressing was last changed. DON stated that this had the potential of resident getting infection and complications from IV site.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to develop a baseline care plan for one of four sampled residents (Resident 1) within 48 hours of resident's admission.
This deficient practi...
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Based on interview, and record review, the facility failed to develop a baseline care plan for one of four sampled residents (Resident 1) within 48 hours of resident's admission.
This deficient practice had the potential for delayed administration of necessary care and services.
Findings:
A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 8/4/2023, with diagnoses including convulsion ( a sudden, irregular movement of the body), and muscle weakness.
A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/9/2023, indicated the resident had intact cognition (decisions consistent/reasonable). The MDS indicated the resident was independent with bed mobility, transfer, toilet use, dressing, and walking. However, she required supervision as it relates to her personal hygiene.
A review of Resident 1`s Assessments on 8/19/2023 at 9:25 AM, indicated the base line care plan was not completed and the status showed in progress. A further review of the assessments indicated that Safety Device/Mobility Device Assessment, Oral Health Dental Screening, Infection Screening Evaluation, Admission/readmission Screener, Medication Self Administration Screen, and Dehydration Risk Screen were not completed, and the status now read incomplete. Upon selection of these forms, no information was displayed on the screen.
During an interview with Registered Nurse Supervisor 2 (RN 2), on 8/19/2023 at 12:18 PM, RN 2 stated on 8/4/2023, she worked from 3:30 PM until 1:15 AM, and she admitted six residents. RN 2 stated she admitted Resident 1 on 8/4/2023. RN 2 stated, I am still completing some of my assessments for those residents. I got audited from medical records for not completing all admission assessments. RN 2 stated ideally staff are required to complete residents` admitting assessments the same day of their admission. RN 2 stated, When you have six admissions in a day, you are not able to complete all the required assessments. I worked from 8/6/2023 to 8/9/2023, but when you come back to work next day, you have new cases and assignments, and you still need to remember and go back and complete the assessments. RN 2 further stated baseline care plan is required to be completed within 72 hours of residents` admission. RN 2 stated, When it's not documented it's not done. RN 2 confirmed that base line care plan for Resident 1 was not completed along with Safety Device/Mobility Device Assessment, Oral Health Dental Screening, Infection Screening Evaluation, Admission/readmission Screener, Medication Self Administration Screen, and Dehydration Risk Screen. RN 2 stated she had so much work piled up and because of that, did not complete Resident 1`s base line care plan and some assessments.
During an interview with the Director of Nursing (DON), on 8/21/2023 at 11:19 AM, the DON stated a base line care plan needs to be completed with 48 hours of resident`s admission to the facility. The DON stated, Licensed nurses are required to complete the admitting assessments within a good time frame, so we have a good picture of resident upon admission. The DON stated Resident 1`s base line care plan was not completed upon admission. The DON stated the potential outcome is the inability to meet resident immediate care needs.
A review of the facility's policy and procedures titled Care Plans-Baseline, revised December 2016, indicated a baseline plan of care to meet the resident`s immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The intradisciplinary Team (IDT- a group of health care professionals who work together to provide care) will review the healthcare practitioner`s orders and implement a baseline care plan to meet the resident`s immediate care needs including but not limited: initial goal based on admission orders, physician orders, dietary orders, therapy services and social services.
Based on interview, and record review, the facility failed to develop a baseline care plan for one of four sampled residents (Resident 1) within 48 hours of resident's admission.
This deficient practice had the potential for delayed administration of necessary care and services.
Findings:
A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 8/4/2023, with diagnoses including convulsion ( a sudden, irregular movement of the body), and muscle weakness.
A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/9/2023, indicated the resident had intact cognition (decisions consistent/reasonable). The MDS indicated the resident was independent with bed mobility, transfer, toilet use, dressing, and walking. However, she required supervision as it relates to her personal hygiene.
A review of Resident 1`s Assessments on 8/19/2023 at 9:25 AM, indicated the base line care plan was not completed and the status showed in progress . A further review of the assessments indicated that Safety Device/Mobility Device Assessment, Oral Health Dental Screening, Infection Screening Evaluation, Admission/readmission Screener, Medication Self Administration Screen, and Dehydration Risk Screen were not completed, and the status now read incomplete. Upon selection of these forms, no information was displayed on the screen.
During an interview with Registered Nurse Supervisor 2 (RN 2), on 8/19/2023 at 12:18 PM, RN 2 stated on 8/4/2023, she worked from 3:30 PM until 1:15 AM, and she admitted six residents. RN 2 stated she admitted Resident 1 on 8/4/2023. RN 2 stated, I am still completing some of my assessments for those residents. I got audited from medical records for not completing all admission assessments . RN 2 stated ideally staff are required to complete residents` admitting assessments the same day of their admission. RN 2 stated, When you have six admissions in a day, you are not able to complete all the required assessments. I worked from 8/6/2023 to 8/9/2023, but when you come back to work next day, you have new cases and assignments, and you still need to remember and go back and complete the assessments . RN 2 further stated baseline care plan is required to be completed within 72 hours of residents` admission. RN 2 stated, When it's not documented it's not done . RN 2 confirmed that base line care plan for Resident 1 was not completed along with Safety Device/Mobility Device Assessment, Oral Health Dental Screening, Infection Screening Evaluation, Admission/readmission Screener, Medication Self Administration Screen, and Dehydration Risk Screen. RN 2 stated she had so much work piled up and because of that, did not complete Resident 1`s base line care plan and some assessments.
During an interview with the Director of Nursing (DON), on 8/21/2023 at 11:19 AM, the DON stated a base line care plan needs to be completed with 48 hours of resident`s admission to the facility. The DON stated, Licensed nurses are required to complete the admitting assessments within a good time frame, so we have a good picture of resident upon admission . The DON stated Resident 1`s base line care plan was not completed upon admission. The DON stated the potential outcome is the inability to meet resident immediate care needs.
A review of the facility's policy and procedures titled Care Plans-Baseline, revised December 2016, indicated a baseline plan of care to meet the resident`s immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The intradisciplinary Team (IDT- a group of health care professionals who work together to provide care) will review the healthcare practitioner`s orders and implement a baseline care plan to meet the resident`s immediate care needs including but not limited: initial goal based on admission orders, physician orders, dietary orders, therapy services and social services.
Jul 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 F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents receive appropriate treatment and services to inc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents receive appropriate treatment and services to increase, prevent, or maintain the range of motion (ROM- the extent of movement of a joint) mobility for two of five sampled residents (Resident 10, and 11) by failing to:
1. Ensure proper documentation by the Restorative Nursing Assistant (RNA) in the flowsheet when treatment was provided to Resident 10.
2. Ensure proper documentation, notification to the doctor (MD), and care planning for any episodes of RNA treatment refusals for Resident 11.
These deficient practices had the potential to place Resident 10 and 11 at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).
Findings:
1. A review of Resident 10 ' s admission Record (AR) indicated that Resident 10 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs), pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) and Parkinson ' s disease (a disorder in the brain that affects movement, often including tremors).
During a review of Resident 10 ' s Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 5/9/2023, the MDS indicated that Resident 10 had a severely impaired (weakened state or condition) cognition (thought processes) for daily decision making and requiring limited assistance from staff for activities of daily living (ADLs-bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene).
During a review of Resident 10 ' s Physician Order Report (POR), dated 1/23/2023, the POR indicated that Resident 10 had orders for:
RNA for ambulation (walking) with front wheel walker (FWW) five times per week (5X/week) as tolerated.
RNA for sit to stands x10 and ambulation with FWW as tolerated.
During a review of Resident 10 ' s Care Plan (CP), dated 1/23/2023, the CP indicated Resident 10 was at risk for decline with interventions to have Resident 10 on the RNA program daily 5X/week and to monitor response and tolerance.
During a review of Resident 10 ' s Restorative Documentation Survey Report (RDSR) from 6/1/2023 to 7/21/2023, RDSR indicated missing documentation on the following days: 6/2/2023, 6/9/2023, 6/16/2023, 6/23/2023, 6/26/2023, 6/29/2023, 7/3/2023, 7/6/2023, 7/7/2023, 7/10/2023, 7/13/2023, 7/17/2023 and 7/21/2023.
2. A review of Resident 11 ' s AR indicated that Resident 11 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should).
During a review of Resident 11 ' s MDS, dated 4/8/2023, the MDS indicated that Resident 11 has moderately impaired cognition for daily decision making and requiring limited assistance from staff for ADLs.
During a review of Resident 11 ' s POR, dated 4/19/2023, the POR indicated that Resident 11 had an order for RNA ambulation with FWW 5X/week as tolerated.
During a review of Resident 11 ' s RDSR from 6/1/2023 to 7/21/2023, RDSR indicated Resident 11 ' s refusals of RNA treatment on the following days: 6/1/2023, 6/6/2023, 6/7/2023, 6/8/2023, 6/12/2023, 6/15/2023, 6/19/2023, 6/20/2023, 6/21/2023, 6/22/2023, 6/27/2023, 6/28/2023, 7/4/2023, 7/5/2023, 7/11/2023, 7/12/2023, 7/14/2023, 7/18/2023, 7/19/2023 and 7/20/2023.
During a review of Resident 11 ' s CP, undated, the CP indicated Resident 11 was at risk for decline with interventions to have Resident 11 on the RNA program daily 5X per week.
During a review of Resident 11 ' s CP, indicated missing CP for Resident 11 ' s refusals of the RNA treatment.
During a review of Resident 11 ' s Medical Chart (MC), from 6/1/2023 to 7/21/2023, MC indicated missing documentation of any Change in Condition (COC) documentation by the licensed nurses (LN) regarding Resident 11 ' s refusals of the RNA treatment.
During an interview on 7/24/2023 at 1:58 p.m., with the Director of Rehabilitation (DOR), DOR stated, importance of reporting episodes of RNA treatment refusals to the physician for possible decline.
During a concurrent interview and record review on 7/24/2023 at 2:11 p.m., with the Director of Nursing (DON), Resident 10 ' s RDSR was reviewed from 6/1/2023 to 7/21/2023. DON verified missing documentation and stated that RNA should document if treatment was given or not in the RNA flowsheets.
During a concurrent interview and record review on 7/24/2023 at 2:11 p.m., with the DON, Resident 11 ' s MC was reviewed from 6/1/2023 to 7/21/2023. DON verified Resident 11 ' s refusals of RNA treatment, missing refusal care plan and notification to the MD. DON stated that RNA refusals should be communicated to the MD, and care plan should have been implemented during the refusals.
During a review of the facility ' s policy and procedure (P&P) titled, Restorative Nursing Services, revised on 7/2020, the P&P indicated that the goals and objectives are individualized and resident-centered, and are outline in the resident ' s plan of care. P&P also indicated RNA goals may include, supporting and assisting the resident in:
· Adjusting or adapting to changing abilities
· Developing, maintaining or strengthening his/her physiological and psychosocial resources.
· Maintaining his/her dignity, independence and self-esteem and
· Participating int eh development and implementation of his/her plan care.
During a review of the facility ' s P&P, titled, Refusal of Treatment, revised 5/2013, the P&P indicated if a resident ' s refuses treatment, the Unit manager, Charge nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing in order to try to address the resident ' s concerns and explain the consequences. P&P also indicated that when a resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident ' s medical record.
During a review of the facility ' s P&P, titled, Care Plans-Comprehensive, revised 9/2010, P&P indicated that assessments of residents are ongoing and care plans are revised as information about the resident and the resident ' s condition change.
Jul 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
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 one of three sampled residents (Resident 1) who needed to have intermittent catheterization (removing urine from t...
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Based on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) who needed to have intermittent catheterization (removing urine from the bladder by placing a tube into the bladder when a person is unable to empty the bladder on his/her own) received care in accordance with a physician ' s and the facility ' s policy and procedures.
This deficient practice had the potential placed Resident 1 increased risk for urinary tract infection (UTI- infection of the bladder, ureters, or kidneys) and/or bladder rupture (burst).
Findings:
A review of Resident 1 ' s admission record indicated the facility initially admitted Resident 1 on 5/16/2023 with diagnoses including weak immune system, syncope (fainting), and collapse (a loss of consciousness for a short period of time which is caused by a temporary drop in the amount of blood that flows to the brain), and insomnia (trouble falling asleep, staying asleep, or getting good quality sleep).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/20/23, indicated Resident 1 cognitive (mental ability to make decisions of daily living) skills was intact. The MDS further indicated Resident 1 required one person physical for Activities of Daily Living (ADLS - bed mobility, transfer, walk in room, locomotion on and off the unit, dressing, toilet use, and personal hygiene).
During an interview on 7/4/23 at 9:25am, the treatment nurse (Tx Nrs) stated Resident 1 had his indwelling catheter, removed a few days. Tx Nrs stated the facility was performing bladder scans (an ultrasound test used to check the amount of urine is in the bladder) on Resident because Resident 1 had urinary retention (was unable to urinate on his own). The Tx Nrs further stated the nurses were performing bladder scans and intermittent catheterization if Resident 1 had 300 milliliters (mls – unit of measurement) or more urine in the bladder. When asked about the bladder scan results for Resident 1 for any given day, the Tx Nrs stated she would find about the bladder scan at 12 noon when her task was due for Resident 1. The Tx Nrs stated she did not need to know what happened with Resident 1 on the previous shift because no one mentioned or noted any abnormalities in Resident 1 ' s medical chart. The Tx Nrs stated, I did not check [Resident 1 ' s medical chart] because if anything was abnormal, then they (previous shift nurses) would have told me. The Tx Nrs further stated that she was not surprised that Resident 1 had a concern regarding the catheterizations because he [Resident 1] complains all the time.
During an interview on 7/4/2023 at 11:30 am, the Tx Nrs stated she reviewed Resident 1 ' s nurse progress notes and discovered that Resident 1 had a bladder urine retention volume of 768 mls. The Tx Nrs stated the nurses had not catheterized Resident 1 per physician ' s orders because wanted to sleep and refused catheterization. The Tx Nrs confirmed that the nurses should catharized Resident 1 and that she should have checked the documentation on Resident 1 from the previous shift. The Tx Nrs the potential for not catharizing Resident 1 included bladder rupture and damage.
During an interview and record review with the Director of Nursing (DON) on 7/5/23 at 4:41 pm, Resident 1 ' s medical chart was reviewed the DON confirmed that the facility did not catheterize Resident 1 after the bladder scan which indicated a bladder urine volume greater than 300 ml as ordered by the physician. The potential effects would be suprapubic (the area under the belly button) pain and UTI. The DON stated the nurses should have offered to catheterize Resident 1 a few more times and report to a physician if Resident 1 continued to refuse
A review of the facility ' s policy and procedures (P&P) titled, . Catheter Insertion, Male Resident, revised in 10/2010, indicated, the purpose of this procedure is to provide guidelines for the aseptic insertion of a urinary catheter. It continued to indicate the following:
1. Verify that there is a physician's order for this procedure.
2. Review the resident's care plan to assess for any special needs of the resident.
3. Assemble the equipment and supplies as needed.
The P&P further indicated, to notify the supervisor if the resident refuses the procedure, notify the physician of any abnormalities (i.e., bleeding, obstruction, etc.), and report other information in accordance with facility policy and professional standards of practice.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure the residents were free from significant medication error on 7/1/2023 for three of 16 sampled residents (Residents 1, 15, and 16) by ...
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Based on interview and record review the facility failed to ensure the residents were free from significant medication error on 7/1/2023 for three of 16 sampled residents (Residents 1, 15, and 16) by failing to ensure that medications were administered as scheduled at 5 pm.
This deficient practice had a potential to risk for complications related to high blood pressure such strokes, heart attacks and kidney problems, resistance to antibiotic [medication used to treat infections], further weaken the immune system for existing medical conditions for Residents 1 , 15, and 16.
Findings:
A review of Resident 1's admission record indicated the facility initially admitted Resident 1 on 5/16/2023 with diagnoses including weak immune system, syncope (fainting), and collapse (a loss of consciousness for a short period of time which is caused by a temporary drop in the amount of blood that flows to the brain), and insomnia (trouble falling asleep, staying asleep, or getting good quality sleep).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/20/23, indicated Resident 1 cognitive (mental ability to make decisions of daily living) skills was intact. The MDS further indicated Resident 1 required one person physical for Activities of Daily Living (ADLS - bed mobility, transfer, walk in room, locomotion on and off the unit, dressing, toilet use, and personal hygiene).
A review of Resident 1's history and physical dated 5/17/2023, indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 15's admission record indicated the facility initially admitted Resident 15 was on 6/29/2023 with diagnoses including diabetes mellitus (DM- a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), hypertensive heart disease with heart failure (constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation leading to the heart not pumping enough blood according to the body's need), and insomnia.
A review of the facility's document titled, Daily Assignment Schedule, dated 7/1/2023 for the 3 pm-11pm shift, indicated no Licensed Vocational Nurse (LVN) assigned to medication cart number 1. The facility has a total of two medication carts.
A review of the facility's document titled Daily Assignment Schedule dated 7/1/2023 for the 3 pm-11pm shift indicated that there was no LVN assigned to cart number 1 (facility has a total of 2 medication carts, each covering a specific section of the facility).
During an observation and concurrent interview with Resident 1 on 7/4/23 at 8:45am, Resident 1 stated that on Saturday, 7/1/2023, he did not receive his 5 pm medications to be administered with food for his weak immune system. Resident 1 stated he received his 5 pm medication at 7:30 pm without food. Resident 1 further stated that a Certified Nursing Assistant (CNA) notified him that the facility did not have a nurse to administer medications in the whole building [facility] on 7/1/2023, and that a nursing supervisor would report to work at 7:30 pm.
During an observation and concurrent interview with Resident 15 on 7/5/23 at 4:20 pm, Resident 15 stated that he received his evening medication late [unknown time] on 7/1/2023. Resident 15 continued to state that he felt like the facility may never had gotten to him to administer his ordered evening medications.
During a concurrent interview and record review with the Director of Staff Development (DSD) on 7/5/23 at 11:24 am, Resident 1's medical chart was reviewed. The DSD stated and confirmed that the facility asked him to work on 7/1/2023 to administer medications to the residents because no LVN assigned to medication cart 1. The DSD confirmed and stated that Resident 1's medications for weak immune system scheduled to be administered at 6 pm on 7/1/2023, were administered at 7:18 pm.
During a concurrent interview and record review with the Director of Staff Development (DSD) on 7/5/23 at 11:24 am, Resident 15's medical chart was reviewed. The DSD stated that Resident 15's medications scheduled for 5 pm on 7/1/2023 were administered at 8:21 pm. The DSD stated Resident 15's medications included:
1. Apixaban (medication used to prevent blood clots), oral Tablet 5 milligrams (mg- unit of measurement). Give 1 tablet by mouth (PO- per oral) two times a day for deep vein thrombosis (DVT- blood clot),
2. Carvedilol (a medication to slow down the heart rate which makes it easier for the heart to pump blood around the body), PO Tablet 25 MG. Give 1 tablet PO with meals for hypertension (HTN- high blood pressure).
3. Cipro (Ciprofloxacin HCl- antibiotic) give 1 tablet PO two times a day for UTI; and
4. Buprenorphine HCl (Buspirone HCl- medication to treat anxiety [nervousness]) oral tablet 5 MG Give 1 tablet by mouth three times a day for anxiety.
A review of 16's Medical Administration Record (a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) with the DSD on 7/1/2023. Indicated Resident 16 was on the following medications scheduled at 5 pm, were administered at 8:07 pm. Resident 16's medications included:
1. Metoprolol Succinate (medication used to treat HTN) Extended Release (ER) 24 hour 50 mg. Give 1 tablet PO in the afternoon for HTN,
2. Losartan Potassium (medication to treat HTN) PO Tablet 100 mg, Give 1 tablet PO in the afternoon for HTN.
The DSD stated that if medications are given past the one hour window, then a physician should be informed and documented as a medication error. The DSD stated and confirmed that he did not document the late medication administration as an error and did not report the medication errors reported to the residents' primary physicians. The DSD further stated that the potential effect included elevated blood pressure (BP) for missed/late administration of medications and/or cause psychotic (mental illness) symptoms if antipsychotic medications were not administered as ordered.
During an interview on 7/5/23 at 4:41 pm, the Director of Nursing (DON) stated the facility should always have a licensed nurse scheduled for each medication cart for patient safety such as administering medications on time as ordered by physicians. The DON confirmed and stated the facility should have informed the residents' attending/ordering physician's when the residents received their medications late so that physician(s) could be aware of complications related to late medication administration and make necessary changes.
A review of the facility's policy and procedures P&P) titled, Administering Medications, revised 12/2012, indicated, Medications shall be administered in a safe and timely manner, and as prescribed. It further listed the following:
- Medications must be administered in accordance with the orders, including any required time frame.
- Medications must be administered within one (I) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
-The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
- 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.
A review of the facility's P&P titled ,Staffing, revised in 2007, indicated, the facility provides adequate staffing to meet needed care and services for our resident population. It further indicated:
1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services.
2. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan.
3. Other support services (e.g., dietary, activities/recreational, social, therapy, environmental, etc.) are adequately staffed to ensure that resident needs are met.
4. Our facility furnishes information from payroll records setting forth the average numbers and types of personnel (in full-time equivalents) on each shift during at least one (1) week of each quarter to appropriate state agencies as required. Such workweek is selected by the state survey agency.
5. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee.
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
Deficiency F0885
(Tag F0885)
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 inform residents, their representatives, and families of those 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 inform residents, their representatives, and families of those residing in the facility by 5 pm the next calendar day following the occurrence of a single confirmed infection of Coronavirus-19 (Resident 1) for two of three sampled residents (Resident 2 and Resident 3) in accordance with the facility's policy and procedures titled COVID-19 Facility Mitigation Plan, updated 1/16/2023.
This deficient practice had the potential to result in lack of awareness on the COVID-19 status in the facility and could lead to improper infection control practice in the facility.
Finding:
A record review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of a left rib, chronic obstructive pulmonary disease (COPD, group of lung disease that block airflow and make it difficult to breathe), and severe persistent asthma with exacerbation (a disease in which the airways get narrow making it hard to breath).
A record review of Resident 1's Minimum Data Set (MDS, a standardized screening tool), dated 4/26/2023, indicated Resident 1's cognition (though process) was intact.
A record review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included joint replacement surgery and left artificial knee joint.
A record review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognition was moderately impaired.
A record review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 3's diagnoses include syncope (temporary loss of consciousness, fainting), and type 2 diabetes (high blood sugar).
A record review of Resident 3's MDS, dated [DATE], Resident 3's cognition (thought process) was intact.
A record review of Resident 1's Transfer Note, dated 4/28/2023, indicated Resident 1 left the facility to go to General Acute Care Hospital 1 (GACH 1) on 4/27/2023 at 2:15 pm secondary to pain in the abdominal area.
A record review of Resident 1's COVID-19 Report from General Acute Care Hospital 1 (GACH 1), dated 4/27/2023, indicated Resident 1 tested positive for COVID-19 on 4/27/2023 at 4:43 pm.
During an interview on 5/4/2023 at 10:10 am, facility's new Infection Preventionist stated and confirmed she was not aware of any recent positive COVID-19 cases in the facility. The new IP stated and confirmed she was not informed Resident 1 tested positive for COVID-19 last week.
During a phone interview on 5/4/2023 at 10:41 am, the Community Relations and Marketer (CRM) stated and confirmed the facility was made aware on 4/28/2023 via a communication portal between GACH 1's case manager and the facility that Resident 1 tested positive for COVID-19 after being transferred to the hospital from the facility.
During an interview on 5/4/2023 at 11:05 am, the Admissions Coordinator (AC) stated and confirmed Resident 1 was transferred to GACH 1 on 4/27/2023. The AC stated she received a referral from GACH 1's case manager that indicated Resident 1 tested positive for COVID-19 in the hospital after being transferred from the facility. The AC stated she informed the CRM, the Director of Nursing (DON) and the Administrator via email about the hospital's referral which indicated Resident 1 tested positive for COVID-19.
During an interview on 5/4/2023 at 11:27 am, the DON stated and confirmed Resident 1 was transferred to the hospital on 4/27/2023 and the facility received a referral from GACH 1 on 4/28/2023 that indicated Resident 1 tested positive for COVID-19 on 4/27/2023 in the hospital.
During an interview on 5/4/2023 at 12:40 pm, Resident 2, who shared the same room as Resident 1, stated and confirmed he was not informed on any new covid cases or updates in the facility in the last week.
During a concurrent interview and record review on 5/4/2023 at 1:02 pm of the facility's policy titled COVID-19 Facility Mitigation Plan, the administrator stated this policy is the facility's policy on COVID-19 and he read Facility designates Administrator designee and /or Social Services Designee and/or case managers to inform residents, their representatives and families of those residing in the facility by 5:00 pm the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other. The Administrator stated the facility informed the residents and staff per policy on the COVID-19 case in the facility. The administrator stated the Activities Director (AD) did the notification to residents and through resident council. However, during an interview with the AD on 5/4/2023 at 1:24 pm, the AD stated she did not call or inform residents or family members about the COVID case in the facility nor was it discussed in the resident council.
During an interview on 5/4/2023 at 1:33 pm, the Social Services Assistant stated and confirmed the social services department did not inform residents and family members regarding the positive case in the facility. The SSA stated nursing is responsible of notification.
During an interview on 5/4/2023 at 1:51 pm, Registered Nurse Supervisor 1 (RN 1) stated and confirmed the facility's policy regarding informing residents and family members of the positive case in the facility was not carried out.
During an interview on 5/4/2023 at 2:20 pm, Resident 3 stated and confirmed the facility did not inform him or made him aware of any new covid cases in the facility in the past two weeks.
A record review of the facility's policy and procedures titled COVID-19 Facility Mitigation Plan, updated 1/16/2023, indicated Facility designates Administrator designee and /or Social Services Designee and/or case managers to inform residents, their representatives and families of those residing in the facility by 5:00 pm the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of quality for one of five sampled 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 meet professional standards of quality for one of five sampled residents (Resident 1) by failing to
a. Properly document Resident 1's refusal of using the Average volume-assured pressure support (AVAP - a relatively newer modality of non-invasive ventilation that integrates the characteristics of both volume and pressure-controlled non-invasive ventilation) on the Medication Administration Record (MAR) according to facility's policy.
b. Administer Invega (an atypical antipsychotic indicated for the treatment of schizophrenia in adults) medication for the month of January 2023 with no proper documentation if the staffs followed up with the physician according to their policy.
These deficient practices jeopardized Resident 1's health and safety by failing to provide necessary treatment and medication in accordance with the physician order.
Findings:
A review of Resident 1's admission Records indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, congestive heart failure (a condition in which the heart does not pump blood as well as it should), chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), obstructive sleep apnea (OSA - is characterized by episodes of a complete (apnea) or partial collapse (hypopnea) of the upper airway with an associated decrease in oxygen saturation or arousal from sleep. This disturbance results in fragmented, nonrestorative sleep).
A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 4/8/2023, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired and required limited assistance from staff for activities of daily living (ADL-bed mobility, transfer, dressing, toilet use, and personal hygiene).
1) A review of physician's order indicated:
i. AVAP at bedtime and during daytime naps
A review of Resident 1's MAR indicated:
i. AVAP at bedtime and during daytime naps – March 2023 – staff licensed documented checked on MAR indicating Resident 1 was receiving AVAP during daytime naps and at bedtime.
During an interview with Certified Nursing Assistant 1 (CNA 1), on 3/30/2023 at 12:26 p.m., CNA 1 stated, Resident 1 tends to refuse to use her AVAP ventilation during bedtime and daytime naps. CNA 1 stated, Resident 1 would remove the ventilation machine because she doesn't like putting it on even though they would remind her to use it and not to remove it.
During an interview with Registered Nurse 1 (RN 1), on 3/30/2023 at 1:08 p.m., RN 1 stated, Resident 1 tend to remove the AVAP ventilation machine herself especially during the daytime naps. RN 1 stated, if a resident refuses a treatment, they need to properly document in the MAR that resident refused the treatment. RN 1 stated, if they document in the Medication Administration Record (MAR) that the AVAP was given, it doesn't correlate the correct documentation.
2) A review of physician's order indicated:
i. Invega sustenna syringe 156 milligram per milliliter (mg/ml) intramuscularly (injection of a substance into a muscle) one time a day every 28 days
A review of Resident 1's MAR indicated:
i. Invega injection – January 2023 – resident did not receive the medication according to physician's order
During an interview with the Director of Staff and Development (DSD), on 3/30/2023 at 11:58 p.m., DSD stated, Resident 1 is on Invega injection medication every 28 days per physician's order. DSD stated, if a medication was not given, licensed staff should follow up and notify physician and if medication was missing, then need to follow up with the pharmacy. A concurrent review of Resident 1's chart does not indicate why the Invega medication was missed for the month of January.
A review of the facility's policy and procedures (P&P) titled, Requesting, Refusing and/or Discontinuing Care of Treatment , revised May 2017 indicated, residents have the right to request, refuse and/or discontinue treatment prescribed by his or her healthcare practitioner, as well as care routines outlined on the resident's assessment and plan of care. The same P&P also indicated, detailed information relating to the request, refusal or discontinuation of care or treatment will be documented in the resident's medical record.
A review of the facility's P&P titled, Administering Medications , revised April 2019 indicated, medications are administered within one hour of their prescribed time, unless otherwise specified. The same P&P also indicated, if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circler the MAR space provided for that drug and dose.
Mar 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
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of quality for five out of five sampled...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of quality for five out of five sampled residents (Residents 1, 2, 3, 4, and 5) by failing to provide required treatment and medication administration according to the facility's policy.
These deficient practices jeopardized Resident 1, 2, 3, 4, and 5's health and safety by failing to provide necessary treatment in accordance with the physician order.
Findings:
A review of Resident 1's admission records indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including hypothyroidism (or underactive thyroid, happens when your thyroid gland doesn't make enough thyroid hormones to meet your body's needs), anemia (a condition which the blood does not have enough health red blood cells) and generalized muscle weakness.
A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 2/7/2023, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required limited assistance from staff for activities of daily living (ADL-surface transfer, dressing, toilet use and personal hygiene).
A review of Resident 1's Medication Administration Record (MAR) on 2/19/2023 night shift (11:00 pm - 7:00 am), indicated no documentation if the following physician's order were carried out or performed:
a. Monitor pain every shift
b. Monitor vital sign and oxygen saturation every shift
c. Pain medication non-pharmacological intervention every shift
d. Pain medication sedation level every shift
A review of Resident 2's admission records indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), Parkinson's disease (a disorder in the brain that affects movement, often including tremors), and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide).
A review of Resident 2's MDS dated [DATE], indicated Resident 2's cognitive skills for daily decision-making were intact and required extensive assistance from staff for ADL-surface transfer, dressing, toilet use and personal hygiene.
A record review of Resident 2's MAR on 2/19/2023 night shift (11:00 pm - 7:00 am), indicated no documentation if the following physician's order were carried out or performed:
a. Monitor # of hours of sleep every evening and night shift
b. Low bed every shift for safety
c. Monitor for aspiration precautions every shift
d. Monitor for excess sedation, ataxia, drowsiness, dizziness, respiratory depression and fall every shift
e. Monitor for signs and symptoms of bleeding
f. Monitor pain every shift
g. Monitor vital sign and oxygen saturation every shift
h. Titrate off oxygen as tolerated to room air.
A review of Resident 3's admission records indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including 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), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), and generalized muscle weakness and chronic pain.
A review of Resident 3's MDS dated [DATE], indicated Resident 3's cognitive skills for daily decision-making were moderately impaired and required limited assistance from staff for ADL-surface transfer, dressing, toilet use and personal hygiene.
A record review of Resident 3's MAR on 2/19/2023 night shift (11:00 pm - 7:00 am), indicated no documentation if the following physician's order were carried out or performed:
a. Low bed every shift for safety
b. Monitor manifested behavior: crying or tearfulness, withdrawal/self-isolation, insomnia, loss of appetite, suicidal ideation, verbalization of depression, verbalization of feeling worthlessness, every shift
c. Monitor side effects of depression medicine
d. Monitor vital sign and oxygen saturation every shift
A review of the admission records indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle), CKD, and Type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 4's MDS dated [DATE], indicated Resident 4's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADL-surface transfer, dressing, toilet use and personal hygiene.
A review of Resident 4's MAR on 2/19/2023 night shift (11:00 pm - 7:00 am), indicated no documentation if the following physician's order were carried out and followed through:
a. Fluid restriction 1500 millimeter(ml)/day
b. Low bed for safety for safety
c. Monitor for signs and symptoms of bleeding/bruising every shift
d. Monitor pain every shift
e. Monitor vital signs and oxygen saturation every shift
A review of Resident 5's admission records indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including encephalopathy, Type II diabetes, anemia and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities).
A review of Resident 5's MDS dated [DATE], indicated Resident 5's cognitive skills for daily decision-making were severely impaired.
A review of Resident 5's MAR on 2/19/2023 night shift (11:00 pm - 7:00 am), indicated no documentation if the following physician's order were carried out and followed through:
a. Low bed for safety for safety
b. Monitor pain every shift
c. Monitor vital signs and oxygen saturation every shift
d. Pain medication non-pharmacological intervention
e. Pain medication sedation level
During a phone interview with Certified Nursing Assistant 3 (CNA 3), on 2/22/2023 at 1:03 p.m., CNA 3 stated, the Licensed Vocational Nurse 1 (LVN 1) assigned during the night shift on 2/19/2023 was by herself and was not able to provide proper care for all the residents as she was the only licensed nurse assigned to all the residents that night. CNA 3 stated further stated LVN 1 left in the middle of the night without having the next assigned LVN to replaced her, therefore, there was no licensed nurse in the facility for the time being. CNA 3 further stated, he was afraid of what may happen if there was an emergency since they are not allowed to provide care that only a licensed nurse could provide.
During a phone interview with LVN 1, on 2/24/2023 at 1:03 p.m., LVN 1 stated, she worked extra during night shift on 2/19/2023 to cover staffs who called off that night. LVN 1 stated, she was told by the Director of Nursing (DON) that she doesn't need to do any monitoring order for the residents and just administered medications. LVN 1 further stated, she did not know she had to carry physician's order during the night shift. LVN 1 further stated and confirmed, she left without having a licensed nurse in the facility as she was told that it was okay for her to leave without a licensed nurse replacing her.
During an interview with the Director of Nursing (DON), on 2/22/2023 at 2:01 p.m., DON stated licensed nurses should follow physician's order for monitoring and assessing residents such as pain assessment, vital signs, and monitoring behaviors. The DON stated, if these were not carried out, it puts residents at risk for worsening signs and symptoms if there's any, residents may be hypertensive and they won't know about it, residents may have change of condition and they won't be able to find out without proper assessment and monitoring and those symptoms would not be relieved.
A review of the facility's policy and procedures (P&P) titled Medication and Treatment Orders, revised July 2016 indicated, orders for medications and treatments will be consistent with principles of safe and effective order writing.
A review of the facility's P&P titled Routine Resident Checks, revised July 2013 indicated, to ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit . routine resident checks involve .identify any change in the resident's condition, identify whether the resident has any concerns ., etc.
A review of the facility's P&P titled, Pain Assessment and Management, revised March 2015 indicated, assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain .
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 F0726
(Tag F0726)
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:
1. Licensed Vocational Nurse 1 (LVN 1) have the specific 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:
1. Licensed Vocational Nurse 1 (LVN 1) have the specific competencies and skill sets necessary to care for five of five sampled residents (Residents 1, 2, 3, 4, and 5) by failing to provide required necessary treatment according to facility ' s policy
2. Director of Nursing (DON) had the specific competency and skill set necessary to ensure that the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents.
These deficient practices jeopardized Resident 1, 2, 3, 4, and 5's health and safety by failing to administer necessary medications and treatment in accordance with the physician order.
Findings:
A review of Resident 1's admission records indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including hypothyroidism (or underactive thyroid, happens when your thyroid gland doesn't make enough thyroid hormones to meet your body's needs), anemia (a condition which the blood does not have enough health red blood cells) and generalized muscle weakness.
A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 2/7/2023, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required limited assistance from staff for activities of daily living (ADL-surface transfer, dressing, toilet use and personal hygiene).
A record review of Resident 1 ' s Medication Administration Record (MAR) on 2/19/2023 night shift (11:00 pm - 7:00 am), indicated no documentation if the following physician ' s order were carried out and followed through:
Monitor pain every shift
Monitor vital sign and oxygen saturation every shift
Pain medication non-pharmacological intervention every shift
Pain medication sedation level every shift.
A review of Resident 2's admission records indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs), Parkinson ' s disease (a disorder in the brain that affects movement, often including tremors), and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide).
A review of Resident 2's MDS dated [DATE], indicated Resident 2's cognitive skills for daily decision-making were intact and required extensive assistance from staff for ADL-surface transfer, dressing, toilet use and personal hygiene.
A record review of Resident 2 ' s MAR on 2/19/2023 night shift (11:00 pm - 7:00 am), indicated no documentation if the following physician ' s order were carried out and followed through:
a. Monitor # of hours of sleep every evening and night shift
b. Low bed every shift for safety
c. Monitor for aspiration precautions every shift
d. Monitor for excess sedation, ataxia, drowsiness, dizziness, respiratory depression and fall every shift
e. Monitor for signs and symptoms of bleeding
f. Monitor pain every shift
g. Monitor vital sign and oxygen saturation every shift
h. Titrate off oxygen as tolerated to room air.
A review of Resident 3's admission records indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including 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), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), and generalized muscle weakness and chronic pain.
A review of the MDS dated [DATE], indicated Resident 3's cognitive skills for daily decision-making were moderately impaired and required limited assistance from staff for ADL-surface transfer, dressing, toilet use and personal hygiene.
A record review of Resident 3 ' s MAR on 2/19/2023 night shift (11:00 pm - 7:00 am), indicated no documentation if the following physician ' s order were carried out and followed through:
a. Low bed every shift for safety.
b. Monitor manifested behavior: crying or tearfulness, withdrawal/self isolation, insomnia, loss of appetite, suicidal ideation, verbalization of depression, verbalization of feeling worthlessness, every shift
c. Monitor side effects of depression medicine
d. Monitor vital sign and oxygen saturation every shift
A review of Resident 4's admission records indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle), CKD, and Type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of the MDS dated [DATE], indicated Resident 4's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADL-surface transfer, dressing, toilet use and personal hygiene.
A record review of Resident 4 ' s MAR on 2/19/2023 night shift (11:00 pm - 7:00 am), indicated no documentation if the following physician ' s order were carried out and followed through:
a. Fluid restriction 1500 millimeter(ml)/day
b. Low bed for safety for safety
c. Monitor for signs and symptoms of bleeding/bruising every shift
d. Monitor pain every shift
e. Monitor vital signs and oxygen saturation every shift.
A review of Resident 5's admission records indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including encephalopathy, Type II diabetes, anemia and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one ' s daily activities).
A review of the MDS dated [DATE], indicated Resident 5's cognitive skills for daily decision-making were severely impaired.
A record review of Resident 5 ' s MAR on 2/19/2023 night shift (11:00 pm - 7:00 am), indicated no documentation if the following physician ' s order were carried out and followed through:
a. Low bed for safety for safety
b. Monitor pain every shift
c. Monitor vital signs and oxygen saturation every shift
d. Pain medication non-pharmacological intervention
e. Pain medication sedation level
During the phone interview with Certified Nursing Assistant 3 (CNA 3) on 2/22/2023 at 1:03 p.m., CNA 3 stated, the LVN 1 assigned during the night shift on 2/19/2023 was by herself and was not able to provide proper care for all the residents as she was the only licensed nurse assigned to all the residents that night. CNA 3 stated, LVN 1 also left in the middle of the night without having the next assigned LVN to replaced her, therefore, there was no licensed nurse in the facility for the time being. CNA 3 stated, he was afraid of what may happen if there was an emergency since they are not allowed to provide care that only a licensed nurse can.
During the phone interview with LVN 1 on 2/24/2023 at 1:03 p.m., LVN 1 stated, she worked extra during night shift on 2/19/2023 to cover staffs who called off that night. LVN 1 stated, she was told by the DON that she doesn ' t need to do any monitoring order for the residents and just administered medications. LVN 1 stated, she didn ' t know she had to carry physician ' s order during the night shift. LVN 1 stated and confirmed, she left without having a licensed nurse in the facility as she was told that it was okay for her to leave without a licensed nurse replacing her.
During an interview with DON on 2/22/2023 at 2:01 p.m., DON stated he is unsure if there should be always a covered licensed nurses in the facility. DON stated he is not aware that LVN 1 left early on 2/19/2023 without the next covering licensed nurse. DON stated, he did not follow up on this incident. DON further stated, licensed nurses should follow physician ' s order for monitoring and assessing residents such as pain assessment, vital signs, and monitoring behaviors. DON stated, if these were not carried out, it puts residents at risk for worsening signs and symptoms if there ' s any, residents may be hypertensive and they won ' t know about it, residents may have change of condition and they won ' t be able to find out without proper assessment and monitoring and those symptoms would not be relieved.
A review of facility's policy and procedures (P&P) titled, Medication and Treatment Orders, revised July 2016 indicated, orders for medications and treatments will be consistent with principles of safe and effective order writing.
A review of facility's P&P titled, Charge Nurse (job description), undated, indicated the primary purpose of job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants . perform routing charting duties as required and in accordance with established charting and documentation policies and procedures . ensure that nurse ' s notes reflect that the care plan is being followed when administering nursing care or treatment.
A review of facility's P&P titled, Director of Nursing Services (job description), undated, indicated the primary purpose of job position is to plan, organize, develop and direct the overall operation of Nursing Service Department in accordance with current federal, state, and local stands, guidelines, and regulations that govern facility . determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents, assign a sufficient number of licensed practical and/or registered nurses for each tour of duty to ensure that quality care is maintained, monitor absenteeism to ensure that an adequate number of nursing care personnel are on duty at all times.
A review of facility's P&P titled, Routine Resident Checks, revised July 2013 indicated, to ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least once per shift each 8-hour shift . routine resident checks involve entering the resident ' s room and/or identifying the resident elsewhere on the unit to determine if the resident ' s needs are being met, identify any change in the resident ' s condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.
Feb 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
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 ensure that two of four sampled residents (Resident 4 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that two of four sampled residents (Resident 4 and 10) receiving enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) received proper care and services consistent with professional standard of care by failing to ensure proper monitoring and documentation of the amount of liquid consumed by Residents 4 and 10.
This deficient practice had the potential to cause delayed identifications of any possible complications and risk factors related to enteral feeding to Resident 4 and 10.
Findings:
a. A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including metabolic 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), gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) insertion, and adult failure to thrive (FTT-syndrome of weight loss, decreased appetite and poor nutrition).
A review of Resident 4 ' s Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 2/4/2023, indicated Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was impaired and requiring one to two persons assist from staff for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene). MDS also indicated that Resident 3 has an indwelling catheter.
A review of Resident 4 ' s medical record, dated 2/2/2023, indicated an enteral feeding order with [NAME] Farms Peptide (type of feeding) 1.5 at 50 milliliter (ml) per hour for 20 hours and water flushes 250 ml every six hours via GT . Resident 4 ' s medical record also indicated no physician order for monitoring and documentation for Resident 4 ' s daily intake and output (I&O).
A review of Resident 4 ' s care plan, dated 2/1/2023, indicated risk for altered nutrition and risk for dehydrations related to GT feeding with interventions to monitor hydration status and I&O.
A review of Resident 4 ' s medical record, titled, Nutrition Assessment, dated 2/6/2023, indicated Resident 4 has a recommendation to clarify water flushes per shift to more appropriate Resident 4 ' s fluid needs.
b. A review of Resident 10 ' s admission Record indicated Resident 10 was admitted on [DATE], with diagnoses including muscle weakness, dysphagia (difficulty swallowing food or liquid) and abnormalities of gait and mobility.
A review of Resident 10 ' s MDS, dated [DATE], indicated Resident 10 ' s cognitive skills for decision-making was impaired and requiring one to two persons assist with ADLs.
A review of Resident 10 ' s medical record, dated 2/14/2023, indicated an enteral feeding order with Nutren (type of feeding) 2.5 at 45 ml per hour for 20 hours and water flushes to provide 800 ml for 20 hours via GT. Resident 10 ' s medical record also indicated no physician order for monitoring and documentation for Resident 10 ' s daily I&O.
A review of Resident 10 ' s care plan, dated 2/10/2023, indicated risk for altered nutrition and risk for dehydrations related to GT feeding with interventions to monitor hydration status and I&O.
A review of Resident 10 ' s medical record, titled, Nutrition Assessment, dated 2/15/2023, indicated Resident 10 has low sodium level (hyponatremia-occurs when low amount of sodium or body has too much water in the blood).
During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 2/16/2023 at 7:31 a.m., ADON stated that Residents 4 and 10 were missing proper monitoring and documentation of the I&O. ADON stated that all residents with enteral feeding should have an order for an I&O to properly monitor hydration status and possible nutritional issues.
A review of facility ' s policy and procedure (P&P), titled, Enteral Tube Feeding via Continuous Pump, revised 11/2018, indicated reviewing resident ' s care plan and provide for any special needs of the resident and the average fluid intake per day should be recorded in the resident ' s medical record.
A review of facility ' s P&P, titled, Enteral Feedings-Safety Precautions, revised 11/2018, indicated that facility will remain current in and follow accepted best practices in enteral nutrition.
A review of facility ' s P&P, titled, Intake, Measuring and Recording, revised 10/2010, indicated reviewing the resident ' s care plan to assess for any special needs for 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 F0694
(Tag F0694)
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 assure that one of three sampled residents (Resident 2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assure that one of three sampled residents (Resident 2) received care and services consistent with professional standard of care when providing an intravenous (IV) antibiotic therapy (antibiotic medicine that are administered into a vein) by failing to ensure:
1. Peripheral Inserted Central Catheter (PICC line- a type of a Central Venous Catheter [CVC-a catheter placed into a large vein near the heart] was maintained by aspirating (drawing) blood return to confirm patency (absence of blockage or obstruction) prior to administering medication.
2. Documentation of the amount of IV medication that was given via intake and output flowsheet (I&O-monitoring of intake of fluid and output of urine to determine hydration adequacy).
These deficient practices had the potential to cause complications such as infection, occlusions (blockage), thrombosis (blood clot), fluid imbalances and possibly death for Resident 2.
Findings:
A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including endocarditis (inflammation of inner layer of the heart), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should), and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to kidney failure).
A review of Resident 2 ' s Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 1/31/2023, indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was intact and requiring set up to one person assist from staff for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene). MDS also indicated that Resident 2 had issues with shortness of breath or troubled breathing with exertion.
A review of Resident 2 ' s Order Summary Report, dated, 1/26/2023, indicated a physician order for a cefepime hydrochloride (HCI) solution (IV antibiotic medication used for treating infections) 1 gram/50 milliliter via IV every 24 hours for six weeks.
During an observation and a concurrent interview with the Registered Nurse 1 (RN 1), on 2/9/2023 at 11:13 a.m., RN 1 was observed administering cefepime HCL via PICC line without aspirating blood prior to administration of the IV medication. RN 1 stated and verified that Resident 2 had a PICC line and per facility policy that CVC care only needed to be flushed and no need for aspiration of the blood before administering an IV medication.
During a concurrent interview and record review with Licensed Vocational Nurse 1 (LVN 1) on 2/9/2023 at 12:41 p.m., LVN 1 stated and verified missing documentation of the amount of IV medication administered to Resident 2. LVN 1 stated that it was important to document and monitor the amount of IV given due to Resident 2 ' s high risk for fluid imbalances due Resident 2 ' s multiple diagnoses.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 2/16/2023 at 7:31 a.m., ADON stated that Resident 2 ' s IV medication amount should be monitored and documented as an I&O.
During a concurrent interview and record review with the ADON on 2/16/2023 at 8:24 a.m., ADON stated that per facility policy that the staff should aspirate blood prior to administering IV medications via CVC to check patency and due to possible risk of thrombosis
A review of the facility ' s policy and procedures (P&P), titled, Central Venous and Midline Catheter Flushing, revised 4/2016, indicated to aspirate the CVC catheter for blood return to confirm patency prior to administration of medications and solutions. P&P also indicated to document the total amount of medication administered.
A review of the facility ' s P&P, titled, IV Administration of Fluids and electrolytes, revised 4/2016, indicated that the amount of solution administered should be recorded in the resident ' s medical record.
A review of the facility ' s P&P, titled, Measuring and Recording Intake, revised 10/2010, indicated to review the resident ' s care plan to assess for any special needs of 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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of six sampled residents (Residents 3, 11...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of six sampled residents (Residents 3, 11, 12, and 13) with an indwelling catheter (foley catheter-a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services consistent with professional standard of care, by failing to ensure proper monitoring and documentation of the urinary output from the catheter for Residents 3, 11, 12 and 13.
This deficient practice had the potential to cause delayed identification of any possible urinary issues that could have complications and risk factors related to the use of indwelling catheter for Residents 3, 11, 12 and 13.
Findings:
a. A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including urinary retention (difficulty urinating), and benign prostatic hyperplasia (BPH-enlarged prostate gland [male gland]).
A review of Resident 3's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 12/26/2022, indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was impaired and requiring one person assist from staff for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene). MDS also indicated that Resident 3 has an indwelling catheter.
A review of Resident 3's medical record, dated 1/3/2023, indicated an order for a foley catheter care. Resident 3's medical record also indicated missing physician order for monitoring and documentation for Resident 3's daily urinary catheter output measurement.
A review of Resident 3's care plan, dated 1/3/2023, indicated risk for bladder infection related to use of indwelling catheter and urinary retention with interventions to monitor intake and output.
A review of Resident 3's medical record, titled, Nutrition Assessment, dated 12/25/2022, indicated Resident 3 has a poor appetite with low sodium level (hyponatremia-occurs when low amount of sodium or body has too much water in the blood).
b. A review of Resident 11's admission Record indicated Resident 11 was admitted on [DATE], with diagnoses including muscle weakness and abnormalities of gait (ambulation) and mobility.
A review of Resident 11's MDS, dated [DATE], indicated Resident 11's cognitive skills for decision-making was impaired and requiring one person assist with ADLs.
A review of Resident 11's medical record, dated 2/14/2023, indicated an order for a foley catheter care. Resident 11's medical record also indicated missing physician order for monitoring and documentation for Resident 11's daily urinary catheter output measurement.
A review of Resident 11's care plan, dated 2/10/2023, indicated risk for bladder infection related to the need of indwelling catheter and risk for dehydration, dated 2/17/2023 with interventions to monitor intake and output.
A review of Resident 11's medical record, titled, Nutrition Assessment, dated 2/20/2023, indicated Resident 11 has episodes of swelling bilateral feet and urinary retention.
c. A review of Resident 12's admission Record indicated Resident 12 was admitted on [DATE], with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should) and generalized muscle weakness.
A review of Resident 12's MDS, dated [DATE], indicated Resident 12's cognitive skills for decision-making was impaired and requiring one person assist with ADLs.
A review of Resident 12's medical record, dated 2/16/2023, indicated an order for a foley catheter care. Resident 12's medical record also indicated missing physician order for monitoring and documentation for Resident 12's daily urinary catheter output measurement.
A review of Resident 12's care plan, dated 2/15/2023, indicated risk for bladder infection related to the need of indwelling catheter and risk for dehydration, dated 2/17/2023 with interventions to monitor intake and output.
d. A review of Resident 13's admission Record indicated Resident 13 was admitted on [DATE], with diagnoses including urine retention, prostate neoplasm (a new and abnormal growth of tissues) and anemia (disorder in which red blood cells [cells that carry oxygen to all parts of body] are destroyed faster than they can be made).
A review of Resident 13's MDS, dated [DATE], indicated Resident 13's cognitive skills for decision-making was moderately impaired and requiring one person assist with ADLs.
A review of Resident 13's medical record, dated 2/9/2023, indicated an order for a foley catheter care. Resident 13's medical record also indicated missing physician order for monitoring and documentation for Resident 13's daily urinary catheter output measurement.
A review of Resident 13's care plan, dated 2/16/2023, indicated need of indwelling catheter due to urinary retention with interventions to monitor intake and output.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 2/16/2023 at 7:31 a.m., ADON stated that Residents 3, 11, 12, and 13 were missing proper monitoring and documentation of the urinary catheter output. ADON stated that all residents with indwelling catheter should have an order for an I&O to properly monitor urine output for any issues.
A review of facility's policy and procedure (P&P), titled, Urinary Catheter Care, revised 9/2014, indicated to observe the resident's urine level for noticeable increases or decreases and maintain an accurate record of the
Feb 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
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure baseline care plan was developed and implemented within 48 h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure baseline care plan was developed and implemented within 48 hours of admission for one of four sampled residents (Resident 7).
This deficient practice had the potential to negatively affect the provision of care and services for Resident 7.
Findings:
A review of Resident 7's admission Record indicated Resident 7 was admitted to the facility on [DATE], with diagnoses including status post gastrointestinal (GI) surgery, hypertension (HTN-elevated blood pressure), and hyperlipemia (abnormally high levels of fats in the blood).
A review of Resident 7's Minimum Data Set (MDS-a standardized assessment and screening tool), dated 01/03/2023, indicated Resident 7 was cognitively (mental action or process of acquiring knowledge and understanding) intact, and one-person physical assist with activities of daily living (ADLs-bed mobility, surface transfer, walk in room, dressing, toileting, and personal hygiene).
A review of Resident 7's medical chart, indicated there was no baseline care plan developed upon admission.
During an interview and a concurrent record review with the Assistant Director of Nursing (ADON), on 1/16/2023 at 11:42 a.m., ADON stated and verified Resident 7's had no baseline care plan. ADON stated that baseline care planning should be done and documented within 48 hours of admission.
A review of the facility's policy and procedure titled, Care Plans-Baseline, revised 12/2016, indicated, facility will develop baseline plan of care and meet resident's immediate needs within 48 hours of admission. The same policy further indicated that the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individualized comprehensive care plan was developed and doc...
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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 individualized comprehensive care plan was developed and documented by the interdisciplinary team (IDT-a coordinated group of experts from several healthcare fields that actively coordinate treatment goals for the patient) within seven days of completion of the resident assessment (MDS-a standardized assessment and screening tool) for one of four sampled residents (Resident 7).
This deficient practice had the potential for Resident 7 not receiving appropriate care treatment and/or services by the facility.
Cross reference: F655
Findings:
A review of Resident 7's admission Record indicated Resident 7 was admitted to the facility on [DATE], with diagnoses including status post gastrointestinal (GI) surgery, hypertension (HTN-elevated blood pressure), and hyperlipemia (abnormally high levels of fats in the blood).
A review of Resident 7's MDS, dated [DATE], indicated Resident 7 was cognitively (mental action or process of acquiring knowledge and understanding) intact, and one-person physical assist with activities of daily living (ADLs-bed mobility, surface transfer, walk in room, dressing, toileting, and personal hygiene).
A review of Resident 7 ' s medical chart, indicated there was no baseline care plan.
A review of Resident 7 ' s medical chart, indicated that an IDT meeting was completed on 1/12/2023.
During an interview with Resident 7 on 1/15/2023 at 9:38 a.m., Resident 7 stated that care plan meeting was done recently.
During an interview and a concurrent record review with the Assistant Director of Nursing (ADON), on 1/16/2023 at 11:42 a.m., ADON stated and verified Resident 7 had an IDT meeting on 1/12/2023. ADON stated that IDT meeting should be within seven days of the completion of the MDS. The ADON further stated the IDT meeting should have been done on 1/5/2023.
During an interview and a concurrent record review with the Social Service Director (SSD), on 1/16/2023 at 3:42 p.m., SSD stated that facility does not have a specific timeframe to do an IDT meeting and 1/12/2023 was acceptable timing for Resident 7 ' s IDT meeting. SSD stated that care planning was done prior to 1/12/2023. SSD was unable to provide documentation that care planning was completed prior to 1/12/2023.
During an interview with the Director of Nursing (DON), on 1/16/2023 at 4:23 p.m., DON stated and verified IDT meeting was done on 1/12/2023. DON stated that IDT should have been done within 7 days and was not aware of the delay of service.
A review of the facility ' s policy and procedure (P&P), titled, Care Plans-Baseline, revised 12/2016, indicated that facility will develop baseline plan of care and meet resident ' s immediate needs within 48 hours of admission. The same P&P further indicated that the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.
A review of the facility ' s P&P, titled, Care Planning-IDT, revised 9/2013, indicated that a comprehensive care plan for each resident is developed within seven days of completion of the MDS.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure proper sanitation in accordance with professional standards for food service safety by failing to ensure one of four sa...
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Based on observation, interview, and record review the facility failed to ensure proper sanitation in accordance with professional standards for food service safety by failing to ensure one of four sampled dietary staff (DA 2) properly washed hands after cleaning the floor.
This deficient practice had the potential to result in cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) that could lead to foodborne illness to the residents.
Findings:
During a concurrent kitchen observation and interview on 1/15/2023 at 12:02 p.m., DA 2 was observed accidentally dropped a small plate of salad into the floor during the tray line. DA 2 was observed cleaning the floor and proceeded on touching a clean coffee mug and placed it in a clean lunch tray. DA 2 stated that he got very busy and had forgotten to wash his hands. DA 2 also stated that he should have wash his hands before touching the clean coffee mug due to contamination.
During an interview with the Dietary Supervisor (DS), on 1/15/2023 at 12:26 p.m., DS stated that it was important to perform hand washing in between touching dirty to clean because of possible risk of food contamination.
A review of the facility ' s job description (JD) titled, Dietary Aide, undated, indicated that dietary aide will follow established infection control and universal precautions policies and procedures when performing daily tasks.
A review of the facility ' s policy and procedure titled, Hand Washing Procedure, dated 2018, indicated that hand washing is important to prevent the spread of infection. The same policy further indicated hand washing needs to be done after handling soiled dishes; and before and after doing housekeeping procedures.
Nov 2022
31 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 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
Infection Control
(Tag F0880)
Someone could have died · 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 properly prevent and control the spread of COVID-19 (...
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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 properly prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance with the facility's infection prevention and control program (IPCP) policies and follow infection control practices by failing to:
1. Ensure that all residents with COVID-19 infection confirmed by testing, or those residents who are recovering from COVID are placed in a dedicated COVID-19 positive unit (red zone, area in the facility for residents confirmed with COVID-19 infection).
2. Ensure there was a designated breakroom for staff working in the red zone.
3. Ensure that Resident 200 and Resident 201 who are in a red zone room did not share the same restroom with Resident 208 who is in a green zone (area in the facility for non-COVID-19 resident) room.
4. Ensure staff (Licensed Vocational Nurse 1 (LVN 1), Licensed Vocational Nurse (LVN 2), Certified Nursing Assistant 14 (CNA 14), Physical Therapist 1 (PT 1) and Occupational Therapist 1 (OT 1) follow proper personal protective equipment (PPE, specialized clothing or equipment worn by an employee for protection against infectious materials) protocol prior to entering and exiting a red zone room.
5. Ensure isolation rooms for yellow (area in the facility for residents under investigation for possible COVID-19 infection) and red zones have isolation signages and available PPE isolation carts right outside the door for staff to use for three out of 13 isolation rooms.
6. Ensure staff were wearing proper PPE or fit-tested respirator (mask that protect used by filtering out contaminants in the air) in the facility.
7. Ensure that the trash bags were properly discarded inside the trash bin of Residents 10, 1, and 17's room.
8. Ensure that soiled face shields were properly discarded and not placed on top of PPE isolation cart.
9. Ensure the soiled disposable isolation gown was properly discarded after used.
10. Ensure all staffs were screened prior to entering the facility.
11. Ensure facility staff was properly bagging dirty linen before using the laundry chute (a vertical shaft in a building down which dirty clothes and linens can be dropped, to land in a laundry area on a lower floor) per facility policy.
These deficient practices resulted in a total of 27 residents tested positive for COVID-19 within the span of 11 days and have the potential to spread COVID-19 to the other 21 residents, staff, and visitors.
On 11/19/2022 at 6:28 p.m., the State Agency (SA) called an Immediate Jeopardy (IJ) Situation (a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) for not able to established a facility-wide systems for the prevention and control of COVID infections of residents which likely to cause serious complications or death to the 48 in-house residents, staff, and visitors. The facility's Administrator, Director of Nursing (DON) and Infection Preventionist (IPN) were notified of the findings.
On 11/23/2022 at 5:31 p.m., the IJ was removed in the presence of the Administrator, DON, IPN, and Registered Nurse Consultant (RNC) after an on-site verification of the implementation of the acceptable IJ Removal Plan (a plan with interventions to correct the deficient practices) through observation, interview, and record review.
The facility's acceptable IJ Removal Plan included the following:
1. Facility moved Covid positive patients to designated area to reduce the risk of spread (Moving room [ROOM NUMBER] to room [ROOM NUMBER] in back hallway). Following this room move - all Covid positive patients will be in one hallway with access to isolation staff break room. This was completed at 8:00 p.m. on 11/19/2022 by IPN.
2. Facility created an isolation staff break room in room [ROOM NUMBER] (private bathroom included) - in back hallway immediately next to Covid designated area in facility. This was completed at 8 p.m. on 11/19/2022 by IPN.
3. Moved room [ROOM NUMBER] to room [ROOM NUMBER] solved any issue of bathrooms potentially being shared between isolation rooms and non-isolation rooms. This was completed at 8 p.m. on 11/19/2022 by IPN.
4. All staff in-services provided by DON and IPN as follows:
11/19/2022: Evening (PM) Shift - 7:30 p.m.
11/20/2022: Night (NOC) Shift - 7 a.m.
11/20/2022: Morning (AM) Shift - 7a.m.
11/20/2022: All Departments - 1:30 p.m.
Topic: PPE usage in isolation rooms.
All working staff members will be in-serviced as they return to work until all are completed. A staff checklist will be used to keep track. IPN and DON will complete in-services. Shift Supervisor will in-service in their absence as needed. Registry staff will be in-serviced on an on-going basis until Covid outbreak has ended.
5. Signage has been corrected and updated: isolation room signage updated, donning ( put on) and doffing (remove) signage updated, break room and dining room capacity signage updated. This was completed at 3 p.m. on 11/20/2022 by IPN.
6. All staff in-services provided by DON and IPN as follows:
11/19/2022: PM Shift - 7:30 p.m.
11/20/2022: NOC Shift - 7 a.m.,
11/20/2022: AM Shift - 7 a.m.,
11/20/2022: All Departments - 1:30 p.m.
Topic: PPE usage in proper masking with N95 and donning/doffing of PPE.
All working staff members will be in-serviced as they return to work until all are completed. A staff checklist will be used to keep track. IPN and DON will complete in-services. Shift Supervisor will in-service in their absence as needed. Registry staff will be in-serviced on an on-going basis until Covid outbreak has ended.
7. Housekeeping staff in-service provided by Maintenance Director/Supervisor (MS) as follows:
11/19/22: PM Shift - 7:30 p.m.
11/20/22: AM Shift - 7 a.m.
Topic: Proper disposal of PPE trash bins located in the Covid positive patient rooms. CNA to leave PPE trash bin outside the room in the patio area to be picked up by housekeepers at 6 a.m., 3p.m., and 9 p.m., covering all three shifts. All working housekeeping staff members will be in-serviced as they return to work until all are completed. A staff checklist will be used to keep track. MS will complete in-services.
8. All staff in-services provided by DON and IPN as follows:
11/19/22: PM Shift - 7:30 p.m.
11/20/22: NOC Shift - 7 a.m.
11/20/22: AM Shift - 7 a.m.
11/20/2022: All Departments - 1:30 p.m.
Topic: Face shield usage and proper disposal of PPE.
All working staff members will be in-serviced as they return to work until all are completed. A staff checklist will be used to keep track. IPN and DON will complete in-services. Shift Supervisor will in-service in their absence as needed. Registry staff will be in-serviced on an on-going basis until Covid outbreak has ended.
9. All staff in-services provided by Director of Nursing and Infection Preventionist as follows:
11/19/22: PM Shift - 7:30 p.m.
11/20/22: NOC Shift - 7 a.m.
11/20/22: AM Shift - 7 a.m.
11/20/2022: All Departments - 1:30 p.m.
Topic: Proper disposal of PPE
All working staff members will be in-serviced as they return to work until all are completed. A staff checklist will be used to keep track. IPN and DON will complete in-services. Shift Supervisor will in-service in their absence as needed. Registry staff will be in-serviced on an on-going basis until Covid outbreak has ended.
10. Facility Visitation Policy: Outside visits for non-isolated residents when possible and if weather permits, and taking each isolated patient visit case-by-case and trying to accommodate if possible, being done safely and outside if possible. This is being followed by our weekend and full-time Activities Coordinator 1 (AC 1) and Activities Coordinator 2 (AC 2). Communicated out to family members via text message through Repticity kiosk (real-time mass text communications) at 9 p.m. on 11/19/2022. Information was also posted in the front.
11. IPN, serving as Director of Staff Development (DSD)/IP and DSD serving as Treatment Nurse (TN)/backup IPN will immediately begin serving in different roles. IPN will immediately be the full-time IPN - 40 hours a week as of 11/20/2022. TN/DSD was previously a treatment nurse but was currently transitioning/training two newly trained treatment nurses. TN/DSD will take over any DSD duties with assistance from the DSD assistant and serve as backup IPN as needed as of 11/20/2022.
12. Administrator sent out a message of the Covid cases and Covid outbreak to all residents and responsible party contacts located in PointClickCare (PCC - cloud-based healthcare software provider) for residents through Repticity kiosk (The Repticity App is exclusively designed for skilled nursing, senior living, assisted living facilities and hospitals. It works in conjunction with a digital visitor kiosk that replaces your pencil and paper visitor sign in sheet with thermal temperature detection for Covid-19) at 9 p.m. on 11/19/2022 ensuring that all have been communicated of any Covid cases within the Facility.
Cross Reference: F836, F881, F882, F885, F886, and F888
Findings:
1.During a review of the facility's census, dated 11/18/2022, the census indicated the facility had 48 in-house residents that included nine residents housed in the yellow zone and 16 residents housed in the red zone.
During an observation on 11/16/2022 at 6:49 p.m., the facility did not have a clear designation between the eight red zone rooms (room [ROOM NUMBER], 14, 15, 16, 19, 20, 25 and 26) and five yellow zone rooms (room [ROOM NUMBER], 22, 23, 29 and 32). The red zone rooms are scattered in the facility, with yellow zone and green zone rooms in between. In addition, there are no clear signages posted in the facility where the red zone rooms start and ends.
During an interview with IPN on 11/19/2022 at 9:43 a.m., IPN stated that it is necessary to have a clear designation between the red zone, the yellow zone, and the green zone. The IPN added This enables the facility staff to distinguish the isolation rooms for proper infection control, to contain the infection, and prevent further spread.
A review of facility's policy and procedures (P&P), titled COVID-19 Facility Mitigation Management Plan (a plan to reduce loss of life and impact of COVID-19 in the facility), updated on 1/14/2022, indicated that this mitigation plan is credible attempt to manage as many aspects of the pandemic and regualtions as possible at the current time. The P&P also indicated as a measure to limit the movement of Healthcare Staff and conserve PPE, the facility has designated certain rooms/unit for the purpose of admitting known or suspected COVID-19 patients. Rooms 14, 15, 16, 19, 20, 23 are for confirmed positive COVID-19 patients or red zone; Rooms 4, 6, 8, 9, 10, 11, 12, 18, 21, 22, 25, 26, 27 are yellow zones.
A review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updates as of 9/23/2022, indicated Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 (virus that cause COVID) infection when the number of patients with SARS-CoV-2 infection is high. On 11/18/2022 the facility have 16 residents positive for COVID.
2a. During a concurrent observation and interview on 11/19/2022 at 11:19 a.m. with Certified Nursing Assistant 5 (CNA 5) and Certified Nursing Assistant 6 (CNA 6) in employee break room was observed. CNA 5 and CNA 6 were observed eating together in one table. CNA 5 stated she was assigned to red zone and CNA 6 was assigned on both green and yellow zone. CNA 5 stated that the facility did not provide red zone staff with a separate break room.
During a concurrent observation and interview on 11/19/2022 at 11:47 a.m. with CNAs 7 and 8 in employee break room was observed. CNA 7 and CNA 8 were observed eating together in one table. CNA 7 stated that she is assigned in red zone. CNA 8 stated she was assigned in green zone.
2b. A review of the facility's daily assignment schedule, dated, 11/18/2022, indicated CNA 4 was assigned with residents in the red zone room and CNA 1 was assigned with residents in the green zone room.
During an interview with CNA 4 on 11/18/2022 at 10:23 p.m., CNA 4 stated that facility did not have a designated break room for staff that works in the red zone. CNA 4 verified that on 11/18/2022, from 7 p.m. to 7:30 p.m., CNA 4 was sharing the break room with CNA 1.
During an interview with CNA 1 on 11/18/2022 at 11:02 p.m., CNA 1 stated and verified having lunch with CNA 4 since there was no other area to eat separately.
During an interview with the IPN on 11/19/2022 at 9:43 a.m., IPN stated that per facility policy, red zone staff should have a designated break room. IPN verified available empty room in the facility and added they can assign a breakroom for the staff who works in the red zone.
A review of facility's policy and procedures, titled COVID-19 Mitigation Management Plan, updated on 1/14/2022, indicated that as a measure to limit the movement of healthcare staff and conserve PPE, the facility has designated certain rooms/unit for the purpose of admitting known or suspected COVID-19 patients. It further stated that all dedicated healthcare staff will be assigned to care for suspected or confirmed COVID-19 residents during their shift in the designated COVID-19 rooms/unit.
3. A review of Resident 201's admission Record indicated the facility admitted Resident 201 on 11/11/2022 with diagnoses including COVID-19, Type II diabetes (a chronic condition that affects the way the body processes blood sugar), chronic kidney disease (CKD - a longstanding disease of the kidneys leading to renal failure).
A review of the Minimum Data Set (MDS-standardized screening and assessment tool for all residents of long-term care facilities), dated 11/17/2022, indicated Resident 201's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required limited assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, toilet use, and personal hygiene).
A review of Resident 201's laboratory test result, collected on 11/17/2022, indicated Resident 201 was confirmed positive for COVID-19 with symptoms of cough.
During an interview with Resident 201 on 11/18/2022 at 8:20 p.m., Resident 201 stated she tested positive for COVID-19 and symptomatic with cough and congestion. Resident 201 stated, she gets up and uses the restroom for bowel (stool) and bladder (urine) with assistance from staff and they don't clean or disinfect the restroom after use. Resident 201 further stated, she's aware that she shares the restroom with another resident next door.
A review of Resident 200's admission Record indicated the facility admitted Resident 200 on 11/09/2022 with diagnoses including COVID-19, fibromyalgia (a condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures).
A review of the MDS dated [DATE], indicated Resident 200's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs- bed mobility, transfer, toilet use, and personal hygiene.
A review of Resident 200's Situation, Background, Assessment, Recommendation (SBAR- a technique that can be used to facilitate prompt and appropriate communication), dated 11/15/2022, indicated Resident 200 was confirmed positive for COVID-19 with symptoms of non-productive cough.
During an interview with Resident 200 on 11/18/2022 at 8:12 p.m., Resident 200 stated she tested positive for COVID-19 and symptomatic with cough. Resident 200 stated, she gets up and uses the restroom for bowel and bladder with assistance from staff and she don't know if staff clean or disinfect the restroom after use. Resident 200 further stated, she's aware that she shares the restroom with her roommate another resident next door.
A review of Resident 208's admission Record indicated the facility admitted Resident 208 on 11/02/2022 with diagnoses including Parkinson's disease (a disorder in the brain that affects movement, often including tremors), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and hypertension (HTN - elevated blood pressure).
A review of the MDS dated [DATE], indicated Resident 208's cognitive skills for daily decision-making were moderately intact and required limited assistance from staff for ADLs- transfer, toilet use, and personal hygiene.
A review of Resident 208's Care Plan, indicated Resident 208 is at risk for infection related to COVID-19 with interventions to restrict visitors, staff, and residents from being at the facility when presenting with COVID-19 signs or symptoms.
An interview with Resident 208 on 11/18/2022 at 6:50 p.m., Resident 208 stated she gets out of bed and uses the restroom with assistance from staff. Resident 208 further stated, she's aware that she shares the restroom with the residents next door, sometimes she doesn't wear surgical mask or face covering because she forgets.
During an observation of Resident 200 and 201's restroom on 11/18/22 at 8:31 p.m., the restroom is being shared with Resident 208 who is in a green zone room. The restroom has a durable medical equipment (DME) raised toilet seat and does not have any cleaning and disinfectant supply available for staffs to use.
During an interview with IPN on 11/19/2022 at 9:43 a.m., IPN stated and confirmed all three residents, Resident 201, 200 and 208 all shares the same restroom. IPN stated, Resident 201 and Resident 200 should not be sharing the restroom with Resident 208 as this puts Resident 201 and 200 at risk of spreading COVID-19 infection to Resident 208.
A review of facility's P&P, titled Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2019 indicated, DME must be cleaned and disinfected before reuse by another resident.
A review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updates as of 9/23/2022, indicated all non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer ' s instructions and facility policies before use on another patient.
4a. A review of Resident 26's admission Record indicated the facility originally admitted Resident 26 on 10/7/2022 and was re-admitted on [DATE] with diagnoses including testicular hypofunction (illness when a male does not produce enough testosterone (sex hormone), chronic stress disorder and COVID-19.
A review of the MDS dated [DATE], indicated Resident 26's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 26's Physician Order dated 11/15/2022, indicated resident had an order for contact/droplet (precautions used for diseases that can be transmitted during contact with the patient or patient's environment) isolation per facility protocol for COVID-19 monitoring.
A review of Resident 26's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 40's admission Record indicated the facility admitted Resident 40 on 10/17/2022 with diagnoses including neoplasm (a new and abnormal growth of tissues) of bone, brain, liver and lungs, hypertension (HTN-elevated blood pressure) and difficulty in walking.
A review of the MDS dated [DATE], indicated Resident 40's cognitive skills for daily decision-making were intact and required extensive assistance from staff for ADLs.
A review of Resident 40's Physician Order dated 11/11/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring.
A review of Resident 40's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 154's admission Record indicated the facility admitted Resident 154 on 11/2/2022 with diagnoses including syncope (fainting) and collapse, and gastroesophageal reflux disease (GERD-a digestive disease in which stomach acid irritates the flood pipe lining).
A review of the MDS dated [DATE], indicated Resident 154's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 154's Physician order dated 11/11/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring.
A review of Resident 154's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
During a concurrent interview with Resident 154 and Registered Nurse 2 (RN 2) on 11/22/2022 at 11:50 a.m., observed Physical Therapist 1 (PT 1) and Occupational Therapist 1 (OT 1), wearing only an N95 mask and face shield, entered Resident 40 and 154's room from the back door of the patio area and ran exiting the residents' room when seen by the surveyor. RN 2 stated that both rehabilitation staff were working in the red zone and needing to go on their lunch break.
During an interview with Resident 154, on 11/22/2022 at 12:15 p.m., Resident 154 stated that staff was using her room as the exit for the past days and she was not able to sleep.
During a concurrent interview with the Director of Rehabilitation (DOR) on 11/22/2022 at 12:33 p.m., DOR stated that PT 1 and OT 1 was on their lunch break and were unable to interview. DOR stated that PT 1 and OT 1 had completed Resident 26's treatment and unable to exit back from the same room because Resident 26 was symptomatic and PT 1 and OT 1 were uncomfortable going back. DOR stated that PT 1 and OT 1 decided to go to Resident 40 and 154's room instead to exit. DOR also stated and verified that the Director of Nursing (DON) had instructions that staff does not need to don (put on) a gown when entering a red zone if only passing by the room.
4b. During a concurrent observation and interview with the Licensed Vocational Nurse 2 (LVN 2) on 11/22/2022 at 12:08 p.m., observed LVN 2 exited Resident 209 and Resident 26's back door to the patio wearing full PPE (with gown and gloves) and walked over to the sink area. LVN 2 stated, he was going to doff his PPE outside the room but he wanted to walk over to the sink so he can discard his PPE to the trash bin next to the sink and wash his hands after. LVN 2 stated, both residents are COVID-19 positive, and they are in isolation.
A review of Resident 209's admission Record indicated the facility originally admitted Resident 209 on 11/22/2022 and was re-admitted on [DATE] with diagnoses including heart failure, BPH, and muscle weakness.
A review of the MDS dated [DATE], indicated Resident 209's cognitive skills for daily decision-making were severely impaired and required extensive assistance from staff for ADLs.
A review of Resident 209's Physician Order dated 11/19/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring.
A review of Resident 26's admission Record indicated the facility originally admitted Resident 26 on 10/7/2022 and was re-admitted on [DATE] with diagnoses including testicular hypofunction (illness when a male does not produce enough testosterone (sex hormone), chronic stress disorder and COVID-19.
A review of the MDS dated [DATE], indicated Resident 26's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 26's Physician Order dated 11/15/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring.
A review of Resident 26's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
During an interview with the ADON on 11/22/2022 at 1:19 p.m., ADON stated that staffs should not wear their PPE outside the room and immediately doff PPE at the exit door. ADON stated, this puts everyone at risk of spreading the infection throughout the facility.
4c. During a concurrent observation and interview with Certified Nursing Assistant 14 (CNA 14) on 11/23/2022 at 2:27 p.m., CNA 14 was observed exiting Resident 7 and Resident 153's back door to the patio wearing full PPE (with gown and gloves) and was about to enter the room next door. CNA 14 stated, she helped Resident 7 to the bathroom and need to toss the linen to the dirty linen bin, and she doesn't know if should be doffing in the room or outside. CNA 14 stated, both residents tested positive with COVID-19 and they are in the red zone room.
A review of Resident 7's admission Record indicated the facility admitted Resident 7 on 10/24/2022 with diagnoses including anemia, dysphagia, and UTI.
A review of the MDS dated 1027/2022, indicated Resident 7's cognitive skills for daily decision-making were moderately impaired and required limited to extensive assistance from staff for ADLs.
A review of Resident 7's Care Plan initiated on 11/19/2022 for risk for worsening signs and symptoms of infection due to positive result of COVID-19 test with interventions including observe transmission-based precautions - contact, droplet, airborne and use of indicated PPE.
A review of Resident 153's admission Record indicated the facility originally admitted Resident 153 on 11/8/2022 with diagnoses including hypertension, hyperlipidemia and muscle weakness.
A review of the MDS dated [DATE], indicated Resident 153's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 153's Physician order dated 11/18/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring.
During an interview with DON on 11/23/2022 at 3:10 p.m., DON stated staffs should be doffing inside the room prior to exiting a red zone room. DON stated, they will do an in-service and education to the staffs to make sure they are aware of the guidelines on proper PPE protocol.
4d. A review of Resident 153's admission Record indicated the facility admitted Resident 153 on 11/18/2022 with diagnoses including right hip replacement (hip joint is replaced by a prosthetic implant [artificial device that replaces a missing body part]) surgery, hypertension (HTN-elevated blood pressure) and difficulty in walking.
A review of the MDS dated [DATE], indicated Resident 153's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs- bed mobility, dressing, toilet use, and personal hygiene.
A review of Resident 153's Physician Order dated 11/18/2022, indicated resident had an order for contact/droplet (precautions used for diseases that can be transmitted during contact with the patient or patient's environment) isolation per facility protocol for COVID-19 monitoring.
A review of Resident 153's laboratory test result dated 11/18/2022, indicated resident was confirmed positive for COVID-19.
During an observation on 11/18/2022 at 7:14 p.m., no isolation signage and no PPE cart was observed right outside Resident 153's room.
During a concurrent observation and interview with the Licensed Vocational Nurse 1 (LVN 1) on 11/18/2022 at 7:24 p.m., observed LVN 1 entered Resident 153's room wearing only an N95 mask and an eye protection. LVN 1 stated that as per her knowledge, Resident 153's room did not need donning (putting on) a PPE prior to entering, therefore, no need for an isolation signage and PPE cart since Resident 153 was only in a yellow zone, not in the red zone room.
During an interview with the DON on 11/18/2022 at 9:19 p.m., DON stated that Resident 153 was supposed to be in the yellow zone room due to exposure to another resident that tested positive with COVID-19. DON also stated that donning (putting on) a gown and gloves must be done before entering a yellow zone room and removing it prior to exiting the room.
During an interview with the IPN on 11/19/2022 at 9:43 a.m., IPN stated that upon entering a yellow and red zone rooms, all staff must don PPE and doff (remove) before exiting the room. IPN also stated and verified Resident 153 was confirmed positive with COVID-19 starting 11/18/2022 at around 3-4 p.m. IPN stated that she was supposed to put the signage and the PPE cart for Resident 153's room but did not and unsure if it was communicated to the licensed staff. IPN stated that it was important to have the proper isolation signage and PPE cart in an isolation room, so staff are aware of the infection due to high risk for exposure.
A review of facility's P&P, titled, COVID-19 Facility Mitigation Management Plan, updated 1/14/2022, indicated that residents who test positive for COVID-19 should be isolated. P&P also indicated that signs are posted immediately outside resident rooms indicating appropriate infection control and prevention precautions and the required PPE The same P&P also indicated that the IPN will ensure necessary PPE is immediately available outside the resident room.
A review of facility's P&P, titled, Suspected/Confirmed COVID-19 Outbreak Care Protocol, undated, indicated initiating an isolation precaution using PPE prior to entering the room.
A review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updates as of 9/23/2022, indicated health care personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 (virus that cause COVID) infection should adhere to Standard Precautions (a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin and mucous membranes) and use a National Institute for Occupational Safety and Health (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).
5a. A review of Resident 105's admission Record indicated the facility admitted the resident on 10/28/2022, with diagnoses including osteomyelitis (infection of the bone).
A review of Resident 105's MDS dated [DATE], indicated Resident 105 was alert and able to verbalize needs.
During a concurrent interview and observation with Resident 105 on 11/18/2022 at 7:12 p.m , outside the room. No isolation signage regarding resident is on green, yellow, or red zone. During an interview with Resident 105, he had been in yellow zone for few days because he was exposed to a COVID 19 resident. Resident 105 stated that the staff was still using his room as a shortcut and continued to enter his room without any PPE.
5b. During an observation of the facility on 11/18/2022 at 6:49 p.m., at the room where Resident 10, Resident 17, and Resident 1 lives, no isolation signages observed outside the room. A review of the Census indicated the room where Resident 10, Resident 17, and Resident 1 lives is an isolation yellow zone room.
A review of Resident 10's admission Record indicated the facility admitted Resident 10 on 2/13/2020 and readmitted on [DATE] with diagnoses including chronic respiratory failure, COPD and Type II diabetes.
A review of the MDS dated [DATE], indicated Resident 10's cognitive skills for daily decision-making were moderately intact and required l[TRUNCATED]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality...
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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 one of two sampled residents (Resident 17). The facility staff was observed standing over the resident while assisting her during a meal.
This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Resident 17.
Findings:
A review of Resident 17's admission Record indicated the facility admitted Resident 17 on 10/12/2022 with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle).
A review of the Minimum Data Set (MDS-standardized screening and assessment tool for all residents of long-term care facilities), dated 10/17/2022, indicated Resident 17's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required limited to extensive assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, eating, and personal hygiene).
During a meal observation on 11/21/2022 at 12:58 p.m., at Resident 17's room, Resident 17 was observed lying on a bed. Certified Nursing Assistant 12 (CNA 12) was observed standing while feeding Resident 17. Resident 17 was observed extending her neck to look up at CNA 12.
During an interview with CNA 12 on 11/21/2022 at 1:05 p.m., CNA 12 stated, she forgot to sit down while feeding Resident 17. CNA 12 stated, staff should sit down while feeding residents so that they can have face-to-face contact and she can monitor residents closely while feeding them.
During an interview with the Registered Nurse 4 (RN 4) on 11/21/2022 at 1:10 p.m., RN stated, staffs should be sitting down while feeding residents to promote dignity.
A review of the facility's policy and procedures titled Assistance with Meals, revised in July 2017, indicated residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example, not standing over residents while assisting them with meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 156's admission Record indicated resident was originally admitted to the facility 9/29/2021 and re-admit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 156's admission Record indicated resident was originally admitted to the facility 9/29/2021 and re-admitted on [DATE], with diagnoses including congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar).
A review of Resident 156's MDS, dated [DATE], indicated Resident 156's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required limited assistance from staff for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene).
During a concurrent observation and interview with Resident 156 on 11/18/2022 at 8:20 p.m., observed Ventolin HFA inhaler (medication that treat or prevent bronchospasm [when airways go into spasm and contract, making it harder to breathe]) at the bedside table. Resident 156 stated that facility nurse was aware that she keeps it with her since she takes it as needed.
During a concurrent record review and interview on 11/23/2022 at 11:50 a.m., ADON verified missing order, self-administration assessment and care plan for the Ventolin HFA inhaler for Resident 156. ADON stated that upon admission, resident was supposed to get a Self-Administration Assessment and if the resident was approved and/or capable upon assessment, it should have an order for the specific medication to be self-administered by the resident and a care plan. ADON stated that having the medication at bedside without an order have a high risk for not knowing how much they have taken since the resident can take it as much as they want and can overdose on the medicine.
3. A review of Resident 157's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including left knee replacement (hip joint is replaced by a prosthetic implant [artificial device that replaces a missing body part]) surgery, hyperlipidemia (abnormally high levels of fats in the blood) and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing).
A review of Resident 157's MDS, dated [DATE], indicated Resident 157's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
During a concurrent observation and interview with Resident 157 on 11/18/2022 at 8:39 p.m., observed a bottle of Biotin (supplement) 5000 microgram (mcg) on top of the bedside table. Resident 157 stated that facility nurse was aware of the supplement and that she takes it daily.
During a concurrent record review and interview on 11/23/2022 at 11:50 a.m., ADON verified missing order, self-administration assessment and care plan for the Biotin for Resident 157. ADON stated that upon admission, resident was supposed to get a Self-Administration Assessment and if the resident was approved and/or capable upon assessment, it should have an order for the specific medication to be self-administered by the resident and a care plan. ADON stated that having the medication at bedside without an order have a high risk for not knowing how much they have taken since the resident can take it as much as they want and can overdose on the medicine.
A review of facility's Policy and Procedure (P&P), titled Self-administration of Medications, with revised date of 12/2016, indicated that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.
Based on observation, interview, and record review, facility failed to ensure proper assessment was provided by facility's interdisciplinary team (IDT-a coordinated group of experts from several healthcare fields that actively coordinate treatment goals for the resident); documented and care planned for determining medication self-administration to three of three sampled residents (Resident 105, 156 and 157).
This deficient practice had the potential to result in an unsafe medication administration to Resident 105, 156 and 157.
Findings:
1. A review of Resident 105's admission Record indicated the facility admitted the resident on 10/28/2022, with diagnoses including osteomyelitis (infection of the bone), human immunodeficiency virus (HIV-causes AIDS and interferes with the body's ability to fight infections) disease and Kaposi's sarcoma (skin cancer).
A review of Resident 105's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 11/2/2022, indicated Resident 105 was alert and able to verbalize needs.
A review of Resident 105's Physician Order dated 10/28/2022 indicated resident had an order for Triumeq (prescription medication used to treat HIV) oral tablet 600-50-300 milligram (mg) give one tablet by mouth one time a day for HIV.
During a concurrent observation and interview with Resident 105 on 11/18/2022 at 7:12 p.m., inside the resident's room, a triumeq bottle was observed in the bedside table. Resident 105 stated that he always keeps it at bedside because the facility does not carry the medication and the medication was very expensive.
During a concurrent interview and record review on 11/23/2022 at 11:42 a.m. with Assistant Director of Nursing (ADON), Resident 105's medical chart was reviewed. ADON stated that before allowing resident to have self-administration of medications, the staff need to assess the resident and have doctor's order for the self-administration. ADON stated that the physician order for Resident 105 okay to keep home medication Triumeq at bedside was ordered on 11/19/2022 and stated that there was no assessment done for self-administration of medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 15's admission Record indicated the facility originally admitted Resident 15 on [DATE] and readmitted th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 15's admission Record indicated the facility originally admitted Resident 15 on [DATE] and readmitted the resident on [DATE] with diagnoses including COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) and Type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 15's MDS, dated [DATE], indicated the resident's cognitive skills for daily decision-making were intact; Resident 15 required limited assistance from staff for activities of daily living (ADLs)- transfer, dressing, toilet use, and personal hygiene.
During a concurrent observation and interview with Resident 15 on [DATE] at 8:45 p.m., Resident 15 was observed unkempt and disheveled with uncombed hair. Resident 15 stated it had been almost 10 days since the last time he had a shower. Resident 15 further stated that, he was told he could not leave his room because he tested positive with COVID-19. Resident 15 stated the facility had provided him bed bath, but he preferred to get a shower instead of bed bath. Resident 15 also stated he felt disgusted and sweaty, and he did not feel comfortable at all because he felt stinky.
A review of Resident 15's ADL - bathing record indicated, Resident 15 last had a shower on [DATE].
During an interview with Certified Nursing Assistant 9 (CNA 9) on [DATE] at 11:52 a.m., CNA 9 stated, residents tested positive for COVID-19 were not allowed to leave their rooms. CNA 9 stated that they were told residents must stay inside the room. When asked how Covid positive residents took showers, CNA 9 stated the residents did not take showers.
During an interview with the ADON on [DATE] at 12:01 p.m., the ADON stated all residents should be allowed to shower, even COVID-19 positive residents. The ADON stated, the facility has a dedicated shower rooms for COVID-19 residents, which is in Shower room [ROOM NUMBER]. The ADON stated, the facility can also schedule shower time where COVID-19 residents can be given shower last with the shower rooms being cleaned and sanitized in between use.
A record review of the facility's P&P titled, Quality of Life - Dignity, revised in February 2020, indicated, residents 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. Some examples of ways in which respect for choices and values are exercised include personal grooming - residents are groomed as they wish to be groomed.
Based on interview and record review, the facility failed to:
1. Ensure that cardiopulmonary resuscitation (CPR) was not provided to one of three sampled residents (Resident 46) who had a do-not-resuscitate (DNR) code status.
This deficient practice violated the right of Resident 46 and the resident's representative to make self-determination regarding her request for life sustaining treatment.
2. Ensure that the care and services provided for one of one sampled resident (Resident 15) by honoring his preferences and choices for shower.
This deficient practice had the potential to affect Resident 15's sense of well-being, level of satisfaction with life and feeling of self-worth and self-esteem.
Findings:
1. A review of Resident 46's admission record indicated Resident 46, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including pneumonia (infection of the lung) and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe).
A review of Resident 46's admission History and Physical (H&P), dated [DATE], indicated the resident had a capacity to understand and make decisions.
A review of Resident 46's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated the resident had intact cognition (mental action of acquiring knowledge and understanding through thought and the senses).
A review of Resident 46's Physician orders for life sustaining treatment (POLST), dated [DATE], indicated the resident was a DNR signed by both the physician and family member.
A review of Resident 46's progress note, dated [DATE], indicated that a supervisor went to check Resident 46 and noted the resident looked pale and her lips were darker. The Supervisor rubbed the resident's chest and no response was noted; the supervisor checked the resident's pulse and no pulse was noted . Resident 46 was prepared for CPR .(on the same day) at 9:41 p.m., paramedics announced the death of the resident.
During an interview on [DATE] at 3:30 p.m., Registered Nurse 3 (RN 3), who was a licensed vocational nurse (LVN) at that time stated that on [DATE], Resident 46 was found unresponsive and that the POLST was not signed so the staff provided CPR to the resident.
During a concurrent interview and record review on [DATE] at 1:15 p.m., with Assistant Director of Nursing (ADON), Resident 46's medical record was reviewed. The ADON stated that according to the POLST, the resident was a DNR. The ADON stated that staff should not have provided CPR to Resident 46 when she was found unresponsive. The ADON also stated that the staff went against Resident 46's wishes of being DNR.
A review of the facility's policy and procedure (P&P) titled Physician orders for life sustaining treatment (POLST) last revised on [DATE], indicated that the facility will advise residents about their rights to make healthcare decisions and the facility will honor those wishes. The California POLST form will be utilized for end for life planning based on the resident's values, beliefs and goals for care and the healthcare professional presents then resident/patient's diagnosis, prognosis, and treatment alternatives. It also indicated that the POLST will be honored if received on admission and signed by both the resident and a physician in accordance with the guidelines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure protection of resident's medical record for one of three sampled residents (Resident 105).
This deficient practice had...
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Based on observation, interview and record review, the facility failed to ensure protection of resident's medical record for one of three sampled residents (Resident 105).
This deficient practice had the potential to violate Resident 105's right to privacy and confidentiality.
Findings:
A review of Resident 105's admission Record indicated the facility admitted Resident 105 on 10/28/2022, with diagnoses including osteomyelitis (infection of the bone), Human immunodeficiency virus (HIV-causes AIDS and interferes with the body's ability to fight infections) disease and Kaposi's sarcoma (skin cancer).
A review of Resident 105's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 11/2/2022, indicated Resident 105 was alert and able to verbalize needs.
During an observation on 11/19/2022 at 9:32 a.m., a laptop screen on top of a medication cart was open and unattended in the hallway, showing Resident 105's information under Registered Nurse 2 (RN 2).
During a concurrent interview and observation on 11/19/2022 at 9: 36 a.m., RN 2 stated that it was supposed to be close before she walked out of the chart due to possible privacy and HIPAA (Health Insurance Portability and Accountability Act) violations.
During an interview with the Assistant Director of Nursing (ADON), on 11/23/2022 at 12:06 p.m., the ADON stated residents' charts must never be left open unattended for privacy issues.
A review of RN 2's file, titled, Corporate Compliance Overview Agreement, signed by RN 2 on 8/25/2022, indicated that the employee shall not use or disclose confidential medical or personal information pertaining to resident's information in accordance with applicable law and policies and procedures.
A review of RN 2's file, titled, Resident's Rights, signed by RN 2 on 8/25/2022, indicated that nursing home residents have the right to confidentiality of personal and clinical records.
A review of RN 2's file, titled, HIPAA/Medical Information Confidentiality Agreement signed by RN 2 on 8/25/2022, indicated that facility staff need to be aware that resident's personal medical information is confidential, protected by law and it is their responsibility to maintain the safeguards to protect information which exist in the form of written/ printed forms, documents, computer stored files or electronically transmitted data.
A review of the facility's policy and procedures, titled, Charting and Documentation, revised 7/2017, indicated that information documented in the resident's clinical record is confidential and may not be released in accordance with state law, HIPAA and facility policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a 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 implement policies and procedures for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act to ensure a staff to resident abuse allegation was reported and investigated timely. Resident 46 complained about a staff being rough on her and broke her back.
This deficient practice had the potential to place the resident at risk for further abuse.
Findings:
A review of Resident 46's admission Record (Face Sheet) indicated Resident 46, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including pneumonia (infection of the lung) and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe).
A review of Resident 46's admission History and Physical (H&P) dated 9/19/2022, indicated resident had a capacity to understand and make decisions.
A review of Resident 46's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/22/2022, indicated the resident had intact cognition (mental action of acquiring knowledge and understanding through thought and the senses).
A review of Resident 46's Progress Notes dated 9/23/2022, indicated resident notified staff that a certified nursing assistant (CNA) was rough with her and injured her back.
During an interview on 11/23/2022 at 3:30 p.m. Registered Nurse 3 (RN3) stated that he spoke to the Resident 46 on 9/23/2022 and told her that the certified nursing assistant inside the room was rough with her and injured her back. RN 3 stated that it is an allegation of abuse, therefore, he reported to the Registered Nurse Supervisor at the time and Director of Nursing. RN 3 stated that all abuse allegations should be reported.
During an interview on 11/23/2022 at 2:40 p.m. with Director of Nursing (DON), stated that he does not think Resident 46's allegation was an abuse. DON further stated that he did not do an investigation on abuse and was not reported to the state licensing, local law enforcement and Ombudsman.
During an interview on 11/22/2022 at 4:25 p.m. with Administrator (ADM), stated that he was not aware of the staff to resident abuse allegation from Resident 46. ADM stated that all abuse allegations including rough handling by the staff should be reported per policy and procedure.
A review of the facility's undated policy and procedure titled Reporting abuse to facility management indicated that it is the responsibility of our employees, facility consultants, attending physicians . to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source and theft or misappropriation of resident property to facility management. It also indicated that employees, facility consultants and/or attending physicians must report any suspected abuse, or incidents of abuse to the administrator promptly. In the absence of the administrator such reports may be made to the Director of nursing or nurse supervisor on duty. It stated that when an alleged or suspected case of mistreatment, neglect, injuries of unknown source or abuse is reported, the facility administrator, or his/her designee will notify the following persons or agencies of such incident:
a. The state licensing/certification agency responsible for surveying/licensing the facility
b. The local state ombudsman
c. Law enforcement officials.
It further stated that upon receiving the reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. The persons performing the investigations must complete a Resident abuse report form and obtain a written, signed and dated statement from the persons reporting the incident. A completed copy of the resident abuse report form and written statements from witnesses if any must be provided to the administrator within 72 hours of the occurrence of such incident. An immediate investigation will be made and a copy of the findings of such investigations will be provided to the administrator within 3 working days of the occurrence of such incident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to report to the State licensing, local law enforcement and Ombudsman...
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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 to the State licensing, local law enforcement and Ombudsman (person appointed to investigate complaints against an institution and seek resolutions to those complaints) regarding an abuse allegation made by one of two sampled residents (Resident 46) against another staff member.
This deficient practice had the potential to result in delay of the investigation of the state licensing, law enforcement and Ombudsman regarding the staff to resident physical abuse allegation.
Findings:
A review of Resident 46's admission record indicated Resident 46, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including pneumonia (infection of the lung) and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe).
A review of Resident 46's admission History and Physical (H&P) dated 9/19/2022, indicated resident had a capacity to understand and make decisions.
A review of Resident 46's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/22/2022, indicated the resident had intact cognition (mental action of acquiring knowledge and understanding through thought and the senses).
A review of Resident 46's progress note dated 9/23/2022, indicated resident notified staff that certified nursing assistant was rough with her and injured her back.
During an interview on 11/23/2022 at 3:30 p.m. Registered Nurse 3 (RN3) stated that he spoke to the Resident 46 on 9/23/2022 and told him that the certified nursing assistant inside the room was rough with her and injured her back. RN 3 stated that it is an allegation of abuse, therefore, he reported to the Registered Nurse Supervisor and Director or Nursing at the time. RN 3 stated that all abuse allegations should be reported.
During an interview on 11/23/2022 at 2:40 p.m. with Director of Nursing (DON), stated that he does not think Resident 46's allegation was an abuse. DON further stated that he did an investigation but was not reported to the state licensing, local law enforcement and Ombudsman.
During an interview on 11/22/2022 at 4:25 p.m. with Administrator (ADM), stated that he was not aware of the staff to resident abuse allegation from Resident 46. ADM stated that all abuse allegations including rough handling by the staff should be reported per policy and procedure.
A review of the facility's undated policy and procedure titled Reporting abuse to facility management indicated that it is the responsibility of our employees, facility consultants, attending physicians . to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source and theft or misappropriation of resident property to facility management. It also indicated that employees, facility consultants and/or attending physicians must report any suspected abuse, or incidents of abuse to the administrator promptly. In the absence of the administrator such reports may be made to the Director of nursing or nurse supervisor on duty. It further stated that when an alleged or suspected case of mistreatment, neglect, injuries of unknown source or abuse is reported, the facility administrator, or his/her designee will notify the following persons or agencies of such incident:
a. The state licensing/certification agency responsible for surveying/licensing the facility
b. The local state ombudsman
c. Law enforcement officials.
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 develop and implement the care plan for two of 21 sampled resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement the care plan for two of 21 sampled residents (Resident 204 and 38) who were at risk for skin breakdown.
This deficient practice had the potential for the residents' specific care needs and current treatments not being monitored for skin breakdown management and its' effectiveness, which could negatively affect Resident 204 and 38's health and wellbeing.
Findings:
1. A review of Resident 204's admission record indicated the facility admitted the resident on 4/23/2021 and readmitted the resident on 11/1/2022 with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), pressure ulcers (an injury that breaks down the skin and underlying tissue) of unspecified part of the back and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down).
A review of Resident 204's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 11/4/2022, indicated Resident 204's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact. The resident required limited to extensive assistance from staff for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene). The MDS also indicated that Resident 204 had an unstageable (stage is not clear) pressure ulcers and was using a pressure reducing device for bed.
A review of Resident 204's Physician Order Summary Report, dated 11/2/2022, indicated an order for Low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) due to pressure injury.
During an observation of Resident 204 on 11/28/2022 at 7:17 p.m., Resident 204 was observed lying on a bed with an LAL mattress.
A review of Resident 204's Care Plan indicated there were no care plans and interventions for the management of her pressure ulcer and the use of an LAL.
During an interview with Assistant Director of Nursing (ADON) on 11/23/2022 at 4:09 p.m., The ADON stated Resident 204' was on LAL mattress to prevent further skin breakdown with an order from the physician. The ADON stated there should be a comprehensive care plan implemented for the use of an LAL mattress. The ADON further stated, the care plan should have been initiated upon order from the physician.
A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered revised in December 2016, 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 same policy also indicated, the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.
2. A review of Resident 38's admission Record indicated the resident was admitted in the facility on 10/12/2022, with diagnoses including [NAME] Nile virus infection (WNV-infection transmitted by the bite of an infected mosquito), metabolic 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) and abnormalities of gait and mobility.
A review of Resident 38's MDS, dated [DATE], indicated the resident was cognitively impaired, and required extensive assistance with ADLs. The MDS further indicated Resident 38 was at risk of developing pressure ulcers/injuries and was being treated by the facility with a pressure reducing device for bed.
A review of Resident 38's Order Summary Report, dated 10/12/2022, indicated to provide a pressure relieving mattress.
A review of Resident 38's Braden Scale (pressure ulcer risk predictor tool) assessment, dated 10/20/2022, indicated Resident 38 was at high risk for pressure ulcer.
A review of Resident 38's Care Plan, dated 10/12/2022, indicated the resident was at high risk for skin breakdown, however, using a pressure relieving device was not included in the care plan per MDS assessment.
During a concurrent record review and interview with Assistant Director of Nursing (ADON), on 11/23/2022 at 3:59 p.m., the ADON stated and verified Resident 38's care plan was not updated with the current treatment. The ADON also stated that care plan must be updated to include the proper and any added treatment that was being provided by the facility such as using an LAL mattress for the prevention of a skin breakdown.
A review of the facility's policy and procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, revised on 12/2016, indicated that the comprehensive person-centered care plan will:
i. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;
ii. Incorporate identified problem areas;
iii. Incorporate risk factors associated with the identified problems;
iv. Aid in preventing or reducing decline in resident's functional status and/or functional levels; and
v. Reflect currently recognized standards of practice for problem areas and condition.
The P&P also indicated that the assessment or residents are ongoing and care plans are reviewed, updated and/or revised by the interdisciplinary team (IDT).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 204's admission record indicated the facility admitted the resident on 4/23/2021 and readmitted the resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 204's admission record indicated the facility admitted the resident on 4/23/2021 and readmitted the resident on 11/1/2022 with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), pressure ulcers of unspecified part of the back (an injury that breaks down the skin and underlying tissue), and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down).
A review of Resident 204's MDS, dated [DATE], indicated Resident 204's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact; the resident required limited to extensive assistance from staff for ADLs. The MDS also indicated that Resident 204 had an unstageable (stage is not clear) pressure ulcers and was using a pressure reducing device for bed.
A review of Resident 204's Physician Order Summary Report, dated 11/2/2022 indicated, an order for Low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) due to pressure injury.
A review of Resident 204's Weights and Vitals Summary, dated 11/15/2022, indicated Resident 204's weight was 98.4 lbs.
During an observation on 11/28/2022 at 7:17 p.m., Resident 204 was observed lying on a bed with an LAL mattress with knob pressure setting at 200 lbs.
During an observation on 11/28/2022 at 10:31 p.m., Resident 204 was observed lying on a bed with an LAL mattress with knob setting at 150 lbs.
During an interview with Director of Nursing (DON) on 11/18/2022 at 10:33 p.m., the DON stated LAL mattress is used to allow alternating pressure to prevent skin injury for residents. When asked how to determine the setting of an LAL mattress, the DON stated, he would have to look into the policy, but the DON also stated the setting of LAL mattress should be based on resident's weight. When asked if Resident 204 weighed 150 lbs. or 200 lbs., the DON stated he would have to look into Resident 204's chart but she (Resident 204) doesn't look like she weighs 200 lbs.
A review of the facility's P&P titled, Support Surface Guidelines revised in September 2013, 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.
A record review of the facility's document titled, Medline Supra DPS - LAL User's Manual, undated, indicated pressure adjust level controls the air pressure output. Higher pressure output will support the heavier weight patient.
Based on observation, interview and record review, the facility failed to provide the necessary treatment and service to two of two sampled residents (Resident 38 and 204) consistent with the resident's needs and professional standard of care by failing to ensure low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was set up properly.
This deficient practice could place Resident 38 and 204 at risk of poor wound healing of the current pressure ulcer and possible development of a new pressure injury.
Findings:
1. A review of Resident 38's admission Record indicated the resident was admitted in the facility on 10/12/2022, with diagnoses including [NAME] Nile virus infection (WNV-infection transmitted by the bite of an infected mosquito), metabolic 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) and abnormalities of gait and mobility.
A review of Resident 38's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 10/18/2022, indicated the resident was cognitively (mental action or process of acquiring knowledge and understanding) impaired, and required extensive assistance with activities of daily living (ADLs-bed mobility, surface transfer, walk in room, dressing, toileting, and personal hygiene). The MDS further indicated Resident 38 was at risk of developing pressure ulcers/injuries and was being treated by the facility with a pressure reducing device for bed.
A review of Resident 38's Order Summary Report, dated 10/12/2022, indicated an order to provide a pressure relieving mattress.
A review of Resident 38's Braden Scale (pressure ulcer risk predictor tool) assessment, dated 10/20/2022, indicated Resident 38 was at high risk for pressure ulcer.
A Review of Resident 38's weights and vitals summary dated 11/11/2022, indicated Resident 38 was 165 pounds (lbs.).
A review of Resident 38's Care Plan, dated 10/12/2022, indicated the resident was at high risk for skin breakdown, however, using a pressure relieving device was not included in the care plan per MDS assessment.
During an initial tour on 11/18/2022 at 8:03 p.m., Resident 38 was observed in bed, lying on an LAL mattress with a setting of a weight of 400 lbs.
During a concurrent interview with Certified Nursing Assistant 2 (CNA 2), on 11/18/2022 at 8:07 p.m., CNA 2 stated that it was not the CNAs' job to check the proper setting of an LAL mattress.
During a concurrent observation, interview, and record review with Registered Nurse 1 (RN 1), on 11/18/2022 at 8:09 p.m., RN 1 stated that it was not his job to check and monitor the setting of the LAL mattress and added that there was a third-party company that should be making sure that setting was properly set. RN 1 verified that Resident 38's LAL mattress should not be set at the 400 lbs. setting since the resident was currently at 165 lbs.
During an interview with Assistant Director of Nursing (ADON), on 11/23/2022 at 3:59 p.m., the ADON stated that the LAL mattress setting should be determined via resident's weight and must be checked by the treatment nurse and the charge nurse for proper setting to prevent any worsening wound or to lower risk of skin breakdown.
A review of the facility's policy and procedure (P&P), titled, Support Surface Guidelines, revised on 9/2013, indicated appropriate pressure reducing and relieving device for residents at risk of skin breakdown. The P&P also indicated that redistributing support surfaces are to promote comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction.
A review of the manufacturer's User's Manual, undated, indicated that according to the weight and height of the patient, to adjust the pressure setting.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2b. A review of Resident 156's admission Record indicated resident was originally admitted to the facility 9/29/2021 and re-admi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2b. A review of Resident 156's admission Record indicated resident was originally admitted to the facility 9/29/2021 and re-admitted on [DATE], with diagnoses including congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 156's MDS, dated [DATE], indicated Resident 156's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required limited assistance from staff for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene).
During a concurrent observation and interview with Resident 156 on 11/18/2022 at 8:20 p.m., observed Ventolin HFA inhaler (medication that treat or prevent bronchospasm [when airways go into spasm and contract, making it harder to breathe]) at the bedside table. Resident 156 stated that facility nurse was aware that she keeps it with her since she takes it as needed.
During a concurrent record review and interview on 11/23/2022 at 11:50 a.m., ADON verified missing order, self-administration assessment and care plan for the Ventolin HFA inhaler for Resident 156. ADON stated that upon admission, resident was supposed to be assessed for ability to medicate self. ADON stated that having the medication at bedside without an order have a high risk for not knowing how much they have taken since the resident can take it as much as they want and can overdose on the medicine.
2c. A review of Resident 157's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including left knee replacement (hip joint is replaced by a prosthetic implant [artificial device that replaces a missing body part]) surgery, hyperlipidemia (abnormally high levels of fats in the blood) and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing).
A review of Resident 157's MDS, dated [DATE], indicated Resident 157's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
During a concurrent observation and interview with Resident 157 on 11/18/2022 at 8:39 p.m., observed a bottle of Biotin (supplement) 5000 microgram (mcg) on top of the bedside table. Resident 157 stated that facility nurse was aware of the supplement and that she takes it daily.
During a concurrent record review and interview on 11/23/2022 at 11:50 a.m., ADON verified missing order, self-administration assessment and care plan for the Biotin for Resident 157. ADON stated that upon admission, resident was supposed to be assessed for ability to medicate self. ADON stated that having the medication at bedside without an order have a high risk for not knowing how much they have taken since the resident can take it as much as they want and can overdose on the medicine.
A review of facility's Policy and Procedure (P&P), titled Storage of Medications, with revised date of 4/2007, indicated that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner.
A review of facility's P&P, titled, Administering Medications, revised 4/2019, indicated that residents may self-administer their own medication only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.
Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards by ensuring:
1. One of two medication carts (Medication Cart 1) was locked and with direct supervision that can prevent residents from unauthorized access to medications.
2. Ensure three of three sampled residents' (Resident 105, 156 and 157) own medication were secured, unattended at bedside and not easily access by any other residents.
These deficient practices had the potential to result in residents unsafely access and taking (ingesting) medications that could harm them.
Findings:
1. During an observation on 11/19/2022 at 12:20 p.m., Medication Cart 1 was observed in front of a room unlocked.
During a concurrent observation and interview on 11/19/2022 at 12:25 p.m., Licensed Vocational Nurse 4 (LVN 4) in front of the Medication Cart 1, confirmed that it was unlocked. LVN 4 stated that she was inside her resident's room. LVN 4 stated that the medication carts should be secured and locked if not use.
A review of facility's policy and procedure titled Security of Medication Cart with revised date of 4/2007, indicated that medication cart shall be secured during medication passes. It also indicated that medication carts must be securely locked at all times when out of nurse's view.
2a. A review of Resident 105's admission Record (face sheet) indicated the facility admitted the resident on 10/28/2022, with diagnoses including osteomyelitis (infection of the bone), human immunodeficiency virus (HIV-causes AIDS and interferes with the body's ability to fight infections) disease and Kaposi's sarcoma (skin cancer).
A review of Resident 105's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 11/2/2022, indicated Resident 105 was alert and able to verbalize needs.
A review of Resident 105's Physician Order dated 10/28/2022 indicated resident had an order for Triumeq (prescription medication used to treat HIV) oral tablet 600-50-300 milligram (mg) give one tablet by mouth one time a day for HIV.
During a concurrent observation and interview with Resident 105 on 11/18/2022 at 7:12 p.m., inside the resident's room, a triumeq bottle was observed in the bedside table. Resident 105 stated that he always keeps it at bedside because the facility does not carry the medication and the medication was very expensive.
During a concurrent interview and record review on 11/23/2022 at 11:42 a.m. with Assistant Director of Nursing (ADON), Resident 105's medical chart was reviewed. ADON stated that before allowing resident to have self-administration of medications, the staff need to assess the resident and have doctor's order for the self-administration. ADON stated that the physician order for resident 105 okay to keep home medication Triumeq at bedside was ordered on 11/19/2022 and stated that there was no assessment done for self-administration of medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and update basic life support/ Cardio Pulmonary Resuscitat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and update basic life support/ Cardio Pulmonary Resuscitation (BLS/CPR) certification, nursing competencies and skills set per facility policy to five of nine sampled facility licensed nurses (Assistant Director of Nursing-ADON, Treatment Nurse/Director of Staff Development-TN/DSD, Licensed Vocational Nurse 3-LVN 3, LVN 4, and LVN 6).
This deficient practice had the potential for residents not receiving the appropriate nursing and related services from licensed nursing staff due to their not updated competency check and expired certification.
Findings:
During an interview with the Infection Preventionist Nurse (IPN) on [DATE] at 9:18 a.m., the IPN stated that she currently had a dual role as the IPN and as the Director of Staff Development (DSD), working Tuesday and Thursday as the IPN and Monday, Wednesday and Fridays as the DSD.
A review of the staff files on [DATE] and [DATE], indicated missing and/or not updated BLS/CPR for the following staff:
ADON, BLS/CPR expired on [DATE]
TN/DSD, BLS/CPR expired on [DATE]
LVN 6, missing BLS/CPR
A review of the staff files on [DATE] and [DATE], indicated missing and/or not updated skills competency checklist for the following staff:
ADON- Date of Hire: [DATE], last skills competency checklist completion: [DATE]
TN/DSD- Date of Hire: [DATE], last skills competency checklist completion: [DATE]
LVN 3- Date of Hire: [DATE], last skills competency checklist completion: [DATE]
LVN 4- Date of Hire: [DATE], last skills competency checklist completion: [DATE]
During a concurrent interview and record review of the staff files with the Administrator (ADM) on [DATE] at 5:26 p.m., the ADM stated that facility staff should have skills and competencies done during the hiring process and in a yearly basis for the CNAs; the ADM also stated BLS/CPR and certifications should be updated in the file by the IPN.
A concurrent interview and record review of the staff files with the Director of Nursing (DON) on [DATE] at 6:33 p.m., DON stated all the needed updates for each nursing staff must be done by the IPN and her assistant.
During a concurrent interview and record review of the staff files with the Director of Nursing (DON) on [DATE] at 6:33 p.m., the DON stated all the needed updates for each nursing staff must be done by the IPN and her assistant.
During an interview with the IPN via phone call on [DATE] at 8:03 p.m., the IPN stated that all staff licenses and/or certificates must be updated and filed in the personnel record files. The IPN stated that she was not able to update some of the staff files but that every staff should have an updated skills competency checklist and must be done during orientation, yearly and as needed
A review of the facility's Facility Assessment (FA) 2022, updated on [DATE], indicated that facility staff must have sufficient nursing staff members with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each residents, as determined by the resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required.
A review of the facility's policy and procedure (P&P), titled, Administrative Manual: Personnel, revised 11/2019, indicated that personnel records shall be maintained to include current complete and accurate for all employees and will include information such as professional and verification of license and performance evaluations. The P&P also indicated that a performance evaluation including skills competency will be completed on each employee during the conclusion of his/her 90-day probationary period, and at least annually thereafter, when there has been an unusual change or decline in an employee's work performance and in determining employee promotion, shift/position transfers, demotions, terminations, wage increases, etc. and to improve the quality of the employee's work performance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policies and procedures to maintain and update Certif...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policies and procedures to maintain and update Certified Nursing Assistant (CNA) certification, basic life support/ Cardio Pulmonary Resuscitation (BLS/CPR) certification and skills training competencies in providing nursing and related services to meet each resident's individual needs for six of eight sampled Certified Nursing Assistants (CNA 1, CNA 2, CNA 9, CNA 15, CNA 16, and CNA 17).
This deficient practice had the potential for residents not receiving the appropriate nursing and related services due to expired certifications and incomplete competencies and skills sets check.
Findings:
During an interview with the Infection Preventionist Nurse (IPN) on [DATE] at 9:18 a.m., the IPN stated that she currently had a dual role as the IPN and as the Director of Staff Development (DSD), working Tuesday and Thursday as the IPN and Monday, Wednesday and Fridays as the DSD.
A review of the staff files on [DATE] and [DATE], indicated missing and/or not updated CNA certification and/or BLS/CPR for the following staff:
CNA 1, BLS/CPR expired on [DATE]
CNA 2, CNA certification expired on [DATE]
CNA 9, missing BLS/CPR
CNA 15, BLS/CPR expired on 9/2018
CNA 16, missing BLS/CPR
A review of the staff files on [DATE] and [DATE], indicated missing and/or not updated skills training competency checklist for the following staff:
CNA 1- Date of Hire:[DATE], last skills training competency checklist: [DATE]
CNA 2-Date of Hire: [DATE], last skills training competency checklist: [DATE]
CNA 15-Date of Hire: [DATE], missing skills training competency checklist
CNA 16-Date of Hire: [DATE], last skills training competency checklist: [DATE]
CNA 17-Date of Hire: [DATE], missing skills training competency checklist
During a concurrent interview and record review of the staff files with the Administrator (ADM) on [DATE] at 5:26 p.m., the ADM stated that facility staff should have skills and competencies done during the hiring process and in a yearly basis for the CNAs; the ADM also stated BLS/CPR and certifications should be updated in the file by the IPN.
During a concurrent interview and record review of the staff files with the Director of Nursing (DON) on [DATE] at 6:33 p.m., the DON stated all the needed updates for each nursing staff must be done by the IPN and her assistant.
During an interview with the IPN via phone call on [DATE] at 8:03 p.m., the IPN stated that all staff licenses and/or certificates must be updated and filed in the personnel record files. The IPN stated that she was not able to update some of the staff files but that every staff should have an updated skills competency checklist and must be done during orientation, yearly and as needed.
A review of the facility's Facility Assessment (FA) 2022, updated on [DATE], indicated that facility staff must have sufficient nursing staff members with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each residents, as determined by the resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required. The FA also indicated that nurse aides are required to have continuing competencies no less than 12 months per year.
A review of the facility's policy and procedure (P&P), titled, Administrative Manual: Personnel, revised 11/2019, indicated that personnel records shall be maintained to include current complete and accurate for all employees and will include information such as professional and verification of license and performance evaluations. The P&P also indicated that a performance evaluation including skills competency will be completed on each employee during the conclusion of his/her 90-day probationary period, and at least annually thereafter, when there has been an unusual change or decline in an employee's work performance and in determining employee promotion, shift/position transfers, demotions, terminations, wage increases, etc. and to improve the quality of the employee's work performance.
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 that staffing information posted was updated and with the actual hours on a daily basis for each shift per facility pol...
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Based on observation, interview and record review, the facility failed to ensure that staffing information posted was updated and with the actual hours on a daily basis for each shift per facility policy on six of six sampled days. (11/18/2022 to 11/23/2022).
This deficient practice had the potential to prevent residents and visitors from knowing the accurate and final Direct Care Services Hours Per Patient Day (DHPPD) and possibly residents' need to go unmet.
Findings:
During a concurrent observation and interview with the Director of Nursing (DON), on 11/18/2022 at 6:22 p.m., the DON verified missing nurse staffing hours posting in the lobby and in the nurse station. The DON stated that it was supposed to be in the binder and was being done by the Director of Staff Development (DSD).
During a concurrent observation and interview with the Administrator, on 11/18/2022 at 10:08 p.m., observed nurse staffing hours posted in the side area near the lobby and nursing station. The Administrator stated and verified that nurse hours were just posted this evening. The Administrator further stated the Infection Preventionist Nurse (IPN) who had a dual role as DSD and IPN was supposed to complete and post the nursing staff hours on a daily basis.
During an observation on 11/19/2022 at 8:07 a.m., nurse staffing information posting was dated 11/19/2022, with no actual DHPPD hours and missing designee signature.
During a concurrent observation and interview with the IPN on 11/20/2022 at 8:04 a.m., observed nurse staffing information posting was dated 11/20/2022, with no actual DHPPD hours and missing designee signature. The IPN stated doing the nurse staffing information posting once a day. The IPN further stated she did not input the actual nurse hours because she does not have the actual hours of the staff. The IPN verified and stated that she was not able to post the nurse hours the day before. The IPN further stated she should be posting the nursing hours daily.
During an observation on 11/21/2022 at 7:17 a.m., nurse staffing information posting was dated 11/20/2022, with no actual DHPPD hours and missing designee signature.
During an observation on 11/22/2022 at 9:16 a.m., nurse staffing information posting was dated 11/21/2022, with no actual DHPPD.
During an observation on 11/23/2022 at 9:36 a.m., nurse staffing information posting was dated 11/23/2022, with no actual DHPPD.
A review of the facility's policy and procedures titled, Posting Direct Care Daily Staffing Numbers, revised on 7/2016, indicated, within two hours of beginning of each shift, the number of Licensed Nurses and the number of unlicensed nursing personnel (certified nursing assistants) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. P&P also indicated that shift staffing information shall be recorded on the form and will include information such as:
i. Date for which the information is posted.
ii. The actual time worked during that shift for each category (licensed or non-licensed) and type of nursing staff.
A review of All Facilities Letter (AFL) 21-11 dated 3/17/2021, indicated, facilities are mandated to use the CDPH 612 to record daily census and The Administrator, DON, or designee must sign the census form verifying that the information is true and accurate and unacceptable documentation includes, but is not limited to: substantially similar or modified versions of CDPH 530 or CDPH 612. In addition, in determining time, the actual time will be based upon the calculation of the actual (not scheduled) time worked by direct caregivers while providing skilled nursing care to patients.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and records review, the facility failed to ensure the controlled drug accountability records reconciled with the corresponding electronic medication administration r...
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Based on observations, interviews, and records review, the facility failed to ensure the controlled drug accountability records reconciled with the corresponding electronic medication administration records (eMAR) for one of two sampled residents (Resident 100).
This deficient practice had the potential to result in medication error and/or drug diversion.
Findings:
A review of Resident 100's admission record indicated the facility admitted the resident on 11/15/2022 with diagnosis including multiple fractures of pelvis, compression fracture of thoracic and lumbar area and depression.
A review of Resident 100's history and physical dated 11/15/2022, indicated resident has the capacity to understand and make decisions.
A review of Resident 100's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 11/21/2022, indicated Resident 100 was alert and able to verbalize needs. MDS also indicated that the resident received as needed pain medications and received non-medication interventions for pain. It also indicated that resident had pain almost constantly and made it hard for the resident to sleep at night and limited the day-to-day activities because of the pain.
A review of Resident 100's physician order dated 11/15/2022 indicated resident had an order for oxycodone (narcotic pain medication) hydrochloride (hcl) 10 milligram (mg) give one tablet by mouth every four hours as needed for severe pain.
A review of Resident 100's controlled medication count sheet for Oxycodone 10 mg tablet indicated that the medication were removed on the following day:
11/16/2022 at 5:35 a.m; 11/16/2022 at 9:40 a.m; 11/16/2022 at 2:48 p.m; 11/16/2022 at 8:00pm; 11/17/2022 at 12:18 a.m; 11/17/2022 at 5:57 a.m; 11/17/2022 2:15 p.m; 11/17/2022 time not legible; 11/17/2022 11:25 pm; 11/18/2022 at 3:30 a.m; 11/18/2022 at 8:08 a.m; 11/18/2022 12:50 p.m; 11/18/2022 at 4:53 p.m; 11/18/2022 at 9:00 p.m; 11/19/2022 at 1:00 a.m; 11/19/2022 at 5:00 a.m; 11/19/2022 at 9:30 a.m; 11/19/2022 at 2:32 p.m; 11/19/2022 at 6:30 p.m; 11/20/2022 at 510 a.m.
A review of Resident 100's Medication Administration record for November 2022, indicated oxycodone 10 mg was administered on these days:
11/16/2022 at 12:04 a.m; 11/15/2022 at 5:35 a.m; 11/16/2022 at 9:40 a.m; 11/16/2022 at 2:48 p.m; 11/16/2022 at 7:46 p.m; 11/17/2022 at 12:18 a.m; 11/17/2022 at 5:57 a.m; 11/17/2022 at 2:15 p.m; 11/17/2022 at 11:24 ; .m; 11/18/2022 at 3:31 a.m; 11/18/2022 at 8:08 a.m; 11/18/2022 at 12:53 p.m; 11/18/2022 at 4:53 p.m; 11/19/2022 at 9:30 a.m; 11/19/2022 at 12:33 p.m; 11/19/2022 at 6:30 p.m; 11/20/2022 at 5:12 a.m.
During a concurrent observation, interview and record review on 11/20/2022 at 11:29 a.m., with Licensed Vocational Nurse 3 (LVN 3), oxycodone hydrogen chloride (hcl, Medication for severe pain) narcotic count for Resident 100 was reviewed. LVN 3 stated there were total of 20 tablet of oxycodone was removed in the bubble pack. LVN 3 confirmed and stated according to the eMAR, there were only 17 doses were documented.
During a concurrent interview and record review on 11/20/2022 at 12:15 p.m., with Assistant Director of Nursing (ADON) the narcotic count and eMAR for oxycodone hcl was reviewed. The ADON stated there were total of four doses of oxycodone that was not accounted for in the eMAR. The ADON further stated not been able to account for medications places the resident at risk for under medicating or over medicating the resident with narcotic medication.
A review of the facility's policy and procedures titled administering medications with revised date of 4/2019, indicated, The medications are administered in a safe and timely manager and as prescribed. 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 int eh resident's medical record: a. Date and time the medications were administered; b. The dosage; c. The route of administration .; d. Any results achieved and when those results were observed and signature and title of the persons administering the drug.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0836
(Tag F0836)
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 report an outbreak of positive cases of coronavirus di...
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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 report an outbreak of positive cases of coronavirus disease 19 (COVID-19- a deadly respiratory disease transmitted from person to person) for seven of seven sampled residents (Residents 2, 25, 43, 38, 157, 159, and 160) on 11/10/2022 to the local health officer.
This deficient practice resulted in the delayed inspection from the Department of Public Health.
Cross Reference F880, F882, and F885
Findings:
A review of Resident 2's admission Record indicated the facility originally admitted Resident 2 on 9/8/2022 with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), HTN and muscle weakness.
A review of the MDS dated [DATE], indicated Resident 2's cognitive skills for daily decision-making were moderately impaired and required limited assistance from staff for ADLs- transfer, dressing, toilet use, and personal hygiene.
A review of Resident 2's progress notes dated 11/10/2022, indicated Resident 2 was confirmed positive for COVID-19 and symptomatic, Resident 2 was also transferred to outside hospital on [DATE].
A review of Resident 25's admission Record indicated the facility originally admitted Resident 25 on 10/5/2022 and readmitted on [DATE] with diagnoses including COVID-19, pneumonia (lung infection that inflames air sacs with fluid or pus), and hypertension (HTN - elevated blood pressure).
A review of the Minimum Data Set (MDS-standardized screening and assessment tool for all residents of long-term care facilities) dated 10/11/2022, indicated Resident 25's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required limited assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, toilet use, and personal hygiene).
A review of Resident 25's laboratory test, collected on 11/15/2022 indicated, Resident 25 was confirmed positive for COVID-19.
A review of Resident 38's admission Record indicated that resident was admitted in the facility on 10/12/2022, with diagnoses including [NAME] Nile virus infection (WNV-infection transmitted by the bite of an infected mosquito), metabolic 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) and abnormalities of gait and mobility.
A review of Resident 38's MDS, dated [DATE], indicated resident was cognitively impaired, and extensive assistance with ADLs. MDS further indicated Resident 38 was at risk of developing pressure ulcers/injuries and was being treated by the facility with a pressure reducing device for bed.
A review of Resident 43's admission Record indicated that the facility admitted the resident on 10/25/2022 with diagnoses including left knee joint replacement surgery, hyperlipidemia (abnormally high levels of fats in the blood) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure).
A review of Resident 43's MDS, dated [DATE], indicated Resident 43's cognitive skills for daily decision-making were intact and required supervision to limited assistance from staff for ADLs.
A review of Resident 43's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 157's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including left knee replacement surgery, hyperlipidemia, and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing).
A review of Resident 157's MDS, dated [DATE], indicated Resident 157's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 157's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 159's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including left knee joint replacement surgery (joint is preplaced by a prosthetic implant [artificial device that replaces a missing body part]), HTN and COPD.
A review of Resident 159's MDS, dated [DATE], indicated Resident 159's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 159's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 160's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including syncope and collapse, CKD and hyperlipidemia.
A review of Resident 160's MDS, dated [DATE], indicated Resident 160's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 160's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
During a record review of the Los Angeles County Department of Public Health (LAC DPH) Integrated Reporting Investigation and Surveillance System (IRIS) documentation dated 11/18/2022, indicated that the assigned Public Health Nurse (PHN) for the facility received a report from the Director of Nursing (DON) on 11/18/2022 that the facility currently has seven residents who tested positive with COVID-19.
During a concurrent record review and interview of facility's Line Listing (documents to list COVID-19 positive residents) with Administrator on 11/22/2022 at 4:16 p.m., it was noted that on 11/10/2022, Resident 25 and Resident 2 tested positive with COVID-19; on 11/11/2022, Resident 38 and Resident 160 tested positive with COVID-19; on 11/14/2022, Resident 159, Resident 43 and Resident 157 tested positive with COVID-19. Upon review of the IRIS, all 7 residents were not reported in LAC DPH. The Administrator confirmed and stated, the facility did not notify the local health officer about the 11/10/2022 to 11/14/2022 positive cases of COVID 19.
During an interview with Infection preventionist (IPN), on 11/19/2022 at 10:00 a.m. the IPN stated the first case of COVID 19 was on 11/10/2022.
During an interview on 11/19/2022 at 12:10 p.m. the Administrator (ADM) stated the facility did not notify the local health officer about the 11/10/2022 positive case of COVID 19.
A review of the facility's policy and procedures titled Unusual Occurrent Reporting, with revised date of 11/8/2019, indicated the facility will notify the Department of Health Services, Licensing and Certification, and local health officer (s) by telephone, of all unusual occurrences within twenty-four hours of the occurrence confirmed in writing or fax. Unusual occurrences include but are not limited to epidemic outbreaks and unusual infectious disease occurrences, prevalence of communicable disease .
A review of the facility's policy and procedures titled COVID-19 Facility Mitigation Management Plan, with updated 1/14/2022, indicated the facility electronically reports information about COVID-19 in a standardized format to CDC [The Centers for Disease Control and Prevention, is the national public health agency of the United States] national Healthcare safety network (NHSN) portal. This report must include but is not limited to the following: Suspected and confirmed COVID-19 infections among residents and staff, including residents previously treated for COVID-19.
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 ensure all staff were vaccinated for COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) for one of 13 sampled staff Registered...
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Based on interview and record review, the facility failed to ensure all staff were vaccinated for COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) for one of 13 sampled staff Registered Nurse 1 (RN 1) by failing to administer a complete COVID-19 vaccine series with a booster dose.
This deficient practice had the potential to result in the transmission of COVID-19 among residents, visitors, and staff.
Cross Reference F882
Findings:
A review of the COVID-19 Staff Vaccination Status for Providers form (used to track staff vaccination status) and RN 1's vaccination record indicated that RN 1 received the COVID-19 vaccine with a first dose, a second dose, and no booster dose.
During an interview with RN 1 on 11/19/2022 at 8:36 a.m., RN 1 stated, she had received two doses of Pfizer COVID-19 vaccine with a first dose on 5/6/2021, and a second dose on 5/27/2021, and was eligible for the booster dose on or before 03/21/2022 and had not received it. RN 1 further stated, she did not sign any refusal exemption form but she was aware she was required to get the booster or she can sign a refusal exemption form.
During a concurrent interview and record review with the Infection Prevention Nurse (IPN), on 119/2022 at 9:43 a.m., IPN reviewed RN 1's vaccination records and stated she had received two doses of Pfizer COVID-19 vaccine with a first dose on 5/6/2021, and a second dose on 5/27/2021, and was eligible for the booster dose on or before 03/21/2022 and had not received it. The IPN further confirmed and stated RN 1 did not sign any refusal exemption form regarding the booster shot. The IPN stated all staff should be fully vaccinated and boosted for COVID-19 based on the Centers for Disease Control and Prevention Guidance that indicated staff are booster eligible 5 months after the completion of the primary series (first and second dose) Pfizer COVID-19 vaccine. The IPN stated RN 1 should have received the booster dose and there was no reason why she hadn't received it yet specially that she works in with COVID-19 positive residents. The IPN stated RN 1 worked full time in the facility. The IPN reviewed the facility policy and stated the facility policy is incorrect and outdated. The IPN stated their COVID-19 Mitigation Plan is not updated to the most current guidelines from CMS and CDC.
A review of the facility's policy and procedures titled, COVID-19 Facility Mitigation Management Plan, updated 1/14/2022, indicated the facility will require all current healthcare provider (HCP) and individuals seeking employment to submit proof of vaccination using the only accepted modes.
A review of Centers for Disease Control and Prevention (CDC) - Summary of Guidance for Minimizing the Impact of COVID-19 on Individual Persons, Communities, and Health Care Systems - United States, August 2022, last reviewed on 8/19/2022 indicated, COVID-19 vaccines are highly protective against severe illness and death and provide a lesser degree of protection against asymptomatic and mild infection. Receipt of a primary series alone, in the absence of being up to date with vaccination through receipt of all recommended booster doses, provides minimal protection against infection and transmission. Being up to date with vaccination provides a transient period of increased protection against infection and transmission after the most recent dose, although protection can wane over time. The rates of COVID-19-associated hospitalization and death are substantially higher among unvaccinated adults than among those who are up to date with recommended COVID-19 vaccination, particularly adults aged ?65 years. Emerging evidence suggests that vaccination before infection also provides some protection against post-COVID-19 conditions, and that vaccination among persons with post-COVID-19 conditions might help reduce their symptoms. Continuing to increase vaccination coverage and ensuring that persons are up to date with vaccination are essential to preventing severe outcomes.
A review of CDC - Stay Up to Date with COVID-19 Vaccines Including Boosters, last reviewed on 11/1/2022 indicated, 18 years and older, at least 2 months after 2nd primary series dose or last booster to be updated with COVID-19 vaccine.
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 residents' medical records were updated to indicate that adv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' medical records were updated to indicate that advance directives (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) were discussed and written information were provided to the residents and/or responsible parties for 10 out of 21 sampled residents (Residents 10, 25, 208, 200, 33, 150, 158, 157, 156 and 159).
This deficient practice might violate the residents' and/or the representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for the residents.
Findings:
1. A review of Resident 10's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and Type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 10's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 9/1/2022, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired. Resident 10 required limited assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, toilet use, and personal hygiene).
A review of Resident 10's Physician Orders for Life-Sustaining Treatment (POLST - a form that gives seriously ill patients more control over their end-of-life care) dated 5/10/2019, indicated Resident 10 did not have an Advance Directive and there was no Advance Directive Acknowledgement (ADA) form in the chart.
2. A review of Resident 25's admission Record indicated the facility originally admitted Resident 25 on 10/5/2022 and readmitted the resident on 11/16/2022 with diagnoses including COVID-19 (coronavirus - an infectious disease that can cause respiratory illness in humans), pneumonia (lung infection), cellulitis (bacterial skin infection), and hypertension (HTN - elevated blood pressure).
A review of Resident 25's MDS dated [DATE], indicated Resident 25's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs- transfer, dressing, toilet use, and personal hygiene.
A review of Resident 25's POLST dated 11/16/2022, indicated Resident 25 did not have an Advance Directive and there was no Advance Directive Acknowledgement (ADA) form in the chart.
3. A review of Resident 208's admission Record indicated the facility admitted Resident 208 on 11/02/2022 with diagnoses including Parkinson's disease (a disorder in the brain that affects movement, often including tremors), COPD and HTN.
A review of Resident 208's MDS dated [DATE], indicated the resident's cognitive skills for daily decision-making were moderately intact and required limited assistance from staff for ADLs- transfer, toilet use, and personal hygiene.
A record review of Resident 208's POLST, dated 11/3/2022, indicated the resident did not have any information if Resident 208 had an Advance Directive and there was no Advance Directive Acknowledgement (ADA) form in the chart.
4. A review of Resident 200's admission Record indicated the facility admitted Resident 200 on 11/09/2022 with diagnoses including COVID-19, fibromyalgia (a condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures).
A review of Resident 200's MDS dated [DATE], indicated Resident 200's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs- bed mobility, transfer, toilet use, and personal hygiene.
A review of Resident 200's POLST, dated 11/9/2022, indicated Resident 200 did not have an Advance Directive and there was no Advance Directive Acknowledgement (ADA) form in the chart.
During a concurrent record review and interview with Registered Nurse 4 (RN 4) on 11/20/2022 at 5:33 p.m., RN 4 stated and verified Resident 10, 25, 208 and 200 had missed advance directive information. RN 4 stated that upon admission, admitting nurse should request resident's advance directive status and documentation from the resident and/or resident's family/representatives; and facility will fill out the ADA form as documentation. RN 4 stated that if residents do not have advance directives, facility should offer information regarding their rights to formulate their own advance directives.
During a concurrent record review and interview with Medical Record Director 1 (MR 1) on 11/22/2022 at 6:17 p.m., MR 1 verified missing advance directive forms and documentations in Resident 10, 25, 208, 200's charts.
During an interview with Assistant Director of Nursing (ADON), on 11/23/2022 at 3:59 p.m., the ADON stated that Advance Directive assessment should be done upon admission by the admitting nurse and can be followed up by any nurses. the ADON also stated that documentation is important to see if it was completed and if follow up was needed.
5. A review of Resident 33's admission Record, indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including pneumonia (lung infection), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and metabolic 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).
A review of Resident 33's MDS, dated [DATE], indicated Resident 33's cognitive skills for daily decision-making were moderately impaired and the resident required limited to extensive assistance from staff for ADLs.
A review of Resident 33's Physician Orders, dated 11/17/2022, indicated that Resident 33 had an order for a Do Not Attempt Resuscitation (DNR) in case of emergency.
A review of Resident 33's chart, indicated that the Advanced Directive Acknowledgement (ADA) form was not filled out and there were no other documentations in the resident's chart regarding any follow ups.
During a concurrent record review and interview with RN 4 on 11/20/2022 at 5:13 p.m., RN 4 stated and verified Resident 33's missing advance directive information. RN 4 stated that upon admission, admitting nurse should request resident's advance directive status and documentation from the resident and/or resident's family/representatives; and facility will fill out the ADA form as documentation. RN 4 stated that if residents do not have advance directives, facility should offer information regarding their rights to formulate their own advance directives.
During a concurrent record review and interview with MR 1 on 11/22/2022 at 6:17 p.m., MR 1 verified missing advance directive form and documentation in Resident 33's chart.
During an interview on 11/23/2022 at 3:59 p.m., the ADON stated that Advance Directive assessment should be done upon admission by the admitting nurse and can be followed up by any nurses. The ADON also stated that documentation is important to see if advance directive was completed and if follow up was needed.
6. A review of Resident 150's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), urinary tract infection (UTI-infection in the urinary system [kidneys, bladder, or urethra]) with Escherichia coli (E. coli-type of bacteria) and HTN.
A review of Resident 150's History and Physical (H&P), indicated the resident had the capacity to understand and make decision.
A review of Resident 150's Physician Orders, dated 11/18/2022, indicated that Resident 150 had an order for a DNR in case of emergency.
A review of Resident 150's chart, indicated that the Advanced Directive Acknowledgement (ADA) form was not filled out and there were no other documentations in the resident's chart regarding any follow ups.
During a concurrent record review and interview with RN 4 on 11/20/2022 at 5:13 p.m., RN 4 stated and verified Resident 150's missing advance directive information. RN 4 stated that upon admission, admitting nurse should request resident's advance directive status and documentation from the resident and/or resident's family/representatives; and facility will fill out the ADA form as documentation. RN 4 stated that if residents do not have advance directives, facility should offer information regarding their rights to formulate their own advance directives
During a concurrent record review and interview with MR 1 on 11/22/2022 at 6:17 p.m., MR 1 verified missing advance directive form and documentation in Resident 150's chart.
During an interview on 11/23/2022 at 3:59 p.m., the ADON stated that Advance Directive assessment should be done upon admission by the admitting nurse and can be followed up by any nurses. The ADON also stated that documentation is important to see if advance directive was completed and if follow up was needed.
7. A review of Resident 156's admission Record indicated the resident was originally admitted to the facility 9/29/2021 and re-admitted on [DATE], with diagnoses including congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should), COPD and DM.
A review of Resident 156's MDS, dated [DATE], indicated Resident 156's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 156's Physician Orders, dated 11/15/2022, indicated that Resident 156 had an order to provide full treatment (full code) in case of emergency.
A review of Resident 156's chart, indicated that the ADA form was not filled out and there were no other documentations in the resident's chart regarding any follow ups.
During a concurrent record review and interview with RN 4 on 11/20/2022 at 5:13 p.m., RN 4 stated and verified Resident 156's missing advance directive information. RN 4 stated that upon admission, admitting nurse should request resident's advance directive status and documentation from the resident and/or resident's family/representatives; and facility will fill out the ADA form as documentation. RN 4 stated that if residents do not have advance directives, facility should offer information regarding their rights to formulate their own advance directives.
During a concurrent record review and interview with MR 1 on 11/22/2022 at 6:17 p.m., MR 1 verified missing advance directive form and documentation in Resident 156's chart.
During an interview on 11/23/2022 at 3:59 p.m., the ADON stated that Advance Directive assessment should be done upon admission by the admitting nurse and can be followed up by any nurses. The ADON also stated that documentation is important to see if advance directive was completed and if follow up was needed.
8. A review of Resident 157's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including left knee replacement (hip join is replaced by a prosthetic implant [artificial device that replaces a missing body part]) surgery, hyperlipidemia (abnormally high levels of fats in the blood) and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing).
A review of Resident 157's MDS, dated [DATE], indicated Resident 157's cognitive skills for daily decision-making were intact and the resident required limited assistance from staff for ADLs.
A review of Resident 157's Physician Orders, dated 11/15/2022, indicated that Resident 157 had an order to provide full treatment (full code) in case of emergency.
A record review of Resident 157's chart, indicated that the ADA form was not filled out and there were no other documentations in the resident's chart regarding any follow ups.
During a concurrent record review and interview with RN 4 on 11/20/2022 at 5:13 p.m., RN 4 stated and verified Resident 157's missing advance directive information. RN 4 stated that upon admission, admitting nurse should request resident's advance directive status and documentation from the resident and/or resident's family/representatives; and facility will fill out the ADA form as documentation. RN 4 stated that if resident does not have it, facility should offer information regarding their rights to formulate their own advance directive.
During a concurrent record review and interview with MR 1 on 11/22/2022 at 6:17 p.m., MR 1 verified missing advance directive form and documentation in Resident 157's chart.
During an interview on 11/23/2022 at 3:59 p.m., the ADON stated that Advance Directive assessment should be done upon admission by the admitting nurse and can be followed up by any nurses. The ADON also stated that documentation is important to see if advance directive was completed and if follow up was needed.
9. A review of Resident 158's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including DM, hyperlipidemia and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure).
A review of Resident 158's MDS, dated [DATE], indicated Resident 158's cognitive skills for daily decision-making were intact and the resident required limited assistance from staff for ADLs.
A review of Resident 158's Physician Orders, dated 11/8/2022, indicated that Resident 158 had an order to provide full treatment (full code) in case of emergency.
A review of Resident 158's chart, indicated that the Advanced Directive Acknowledgement (ADA) form was not filled out and there were no documentations in the resident's chart regarding any follow ups.
During a concurrent record review and interview with RN 4 on 11/20/2022 at 5:13 p.m., RN 4 stated and verified Resident 158's missing advance directive information. RN 4 stated that upon admission, admitting nurse should request resident's advance directive status and documentation from the resident and/or resident's family/representatives; and facility will fill out the ADA form as documentation. RN 4 stated that if resident does not have it, facility should offer information regarding their rights to formulate their own advance directive.
During a concurrent record review and interview with MR 1 on 11/22/2022 at 6:17 p.m., MR 1 verified missing advance directive form and documentation in Resident 158's chart.
During an interview on 11/23/2022 at 3:59 p.m., the ADON stated that Advance Directive assessment should be done upon admission by the admitting nurse and can be followed up by any nurses. The ADON also stated that documentation is important to see if advance directive was completed and if follow up was needed.
10. A review of Resident 159's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including left knee joint replacement surgery, HTN and COPD.
A review of Resident 159's MDS, dated [DATE], indicated Resident 159's cognitive skills for daily decision-making were intact and the resident required limited assistance from staff for ADLs.
A review of Resident 159's Physician Orders, dated 11/5/2022, indicated that Resident 159 had an order to provide full treatment (full code) in case of emergency.
A review of Resident 159's chart, indicated that the Advanced Directive Acknowledgement (ADA) form was not filled out and there were no documentations in the resident's chart regarding any follow ups.
During a concurrent record review and interview with RN 4 on 11/20/2022 at 5:13 p.m., RN 4 stated and verified Resident 159's missing advance directive information. RN 4 stated that upon admission, admitting nurse should request resident's advance directive status and documentation from the resident and/or resident's family/representatives; and facility will fill out the ADA form as documentation. RN 4 stated that if resident does not have it, facility should offer information regarding their rights to formulate their own advance directive.
During a concurrent record review and interview with MR 1 on 11/22/2022 at 6:17 p.m., MR 1 verified missing advance directive form and documentation in Resident 159's chart.
During an interview on 11/23/2022 at 3:59 p.m., the ADON stated that Advance Directive assessment should be done upon admission by the admitting nurse and can be followed up by any nurses. The ADON also stated that documentation is important to see if advance directive was completed and if follow up was needed.
A review of the facility's policy and procedure (P&P), titled, Advance Directives, revised 12/2016, indicated that upon admission, the resident will be provided with written information on to formulate an advance directive if he or she chooses to do so. The P&P also indicated that information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record and nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.
A review of the facility's P&P, titled, Physician Orders for Life Sustaining treatment (POLST), revised 3/22/2018, indicated that during the admission process, facility staff should determine whether the resident has an advance directive. The P&P indicated that advance directive should be obtain and attach to the POLST and place documents in the medical record. The P&P also indicated that advance care planning is an integral aspect of the facility's comprehensive care planning process and assures re-evaluation of the resident's desires on a routine basis and when there is a significant change in the resident's condition that can help the resident, family and interdisciplinary team prepare for the time when a resident becomes unable to make decisions or is actively dying.
A review of POLST form, version 1/1/2016, under directions for health care provider, indicated that POLST does not replace the advance directive and must be reviewed to ensure consistency and update forms appropriately to resolve any conflicts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for three of three sampled residents (Resident 33, 100, and 105) by failing to:
1. Develop a comprehensive person-centered care plan when Resident 33 was admitted to hospice care.
2. Develop a comprehensive and resident-centered care plan regarding Resident 100's pain.
3. Develop and implement a comprehensive and resident-centered care plan regarding Resident 105 antibiotic use and peripherally inserted central catheter (PICC line-type of catheter that is placed in a large vein that allows to give medications intravenously [IV-given via vein]) and failed to develop a comprehensive and resident-centered care plan regarding Resident 105's self-administration of medication.
This deficient practice had the potential for the resident to not receive care services specific to resident's needs.
Findings:
1.A review of Resident 33's admission Record (facesheet) indicated resident was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar) and metabolic 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).
A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/31/2022, indicated Resident 33's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired and required limited to extensive assistance from staff for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene).
A record review of Resident 33's Physician Orders, dated 11/16/2022, indicated that Resident 33 had an order for a hospice evaluation and start care on 11/17/2022.
A concurrent record review and interview with the Assistant Director of Nursing (ADON) on 11/23/2022 at 3:59 p.m., ADON stated and verified missing hospice care plan for Resident 33. ADON stated that care plan was supposed to be developed upon receiving hospice care. 2. A review of Resident 100's admission Record indicated the facility admitted the resident on 11/15/2022 with diagnosis including multiple fractures of pelvis, compression fracture of thoracic (spine located in the upper and middle part of the back) and lumbar (bones in the lower back) area and depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
A review of Resident 100's History and Physical (H&P) dated 11/15/2022, indicated resident has the capacity to understand and make decisions.
A review of Resident 100's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 11/21/2022, indicated Resident 100 was alert and able to verbalize needs. MDS also indicated that the resident received as needed pain medications and received non-medication interventions for pain. It also indicated that resident had pain almost constantly and made it hard for the resident to sleep at night and limited the day-to-day activities because of the pain.
A review of Resident 100's Physician Order dated 11/15/2022 indicated resident had an order for oxycodone hydrochloride (narcotic pain medication) 10 milligram (mg) give one tablet by mouth every four hours as needed for severe pain.
A review of Resident 100's Physician Order dated 11/18/2022, indicated resident had an order for dilaudid (narcotic pain medication) two milligram by mouth, give one tablet by mouth as needed for pain management three times a day.
During an interview on 11/18/2022 at 7:50 p.m., Resident 100 stated that his pain is unbearable sometimes and they had been giving him pain medications but was not enough sometimes.
During a concurrent interview and record review on 11/22/2022 at 5:30 p.m., with Assistant Director of Nursing (ADON), Resident 100's medical chart was reviewed. ADON stated that there was no baseline or comprehensive care plan for resident regarding pain medication or pain assessment. ADON stated that the resident needed a care plan for pain because of his diagnosis. ADON stated that the resident was place at risk for unresolved pain.
3. A review of Resident 105's admission Record indicated the facility admitted the resident on 10/28/2022, with diagnoses including osteomyelitis (infection of the bone), human immunodeficiency virus (HIV-causes AIDS and interferes with the body's ability to fight infections) disease and Kaposi's sarcoma (skin cancer).
A review of Resident 105's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 11/2/2022, indicated Resident 105 was alert and able to verbalize needs. MDS also indicated that the resident was getting an antibiotic via intravenously.
A review of Resident 105's Physician Order dated 11/7/2022 indicated an order of Cefepime (antibiotic) hydrochloride two gram/100 milliliter, use two grams intravenously every 12 hours for osteomyelitis until 12/19/2022.
A review of Resident 105's Physician Order dated 10/28/2022 indicated an order Cubicin (antibiotic) solution use 500 milligram (mg) intravenously every 24 hours for osteomyelitis until 12/19/2022.
A review of Resident 105's Physician Order dated 10/28/2022 indicated resident had an order for Triumeq (prescription medication used to treat HIV) oral tablet 600-50-300 milligram (mg) give one tablet by mouth one time a day for HIV.
A review of Resident 105's Care Plan initiated on 11/19/2021, indicated Resident 105 needs IV (intravenously) therapy due to osteomyelitis. One of the interventions was to change IV site, dressing, tubing, solution container per protocol and tape IV catheter and tubing securely.
During a concurrent interview and observation with Resident 105 on 11/18/2022 at 7:12 p.m , inside the room. Resident 105 was observed with a PICC line on right antecubital area. Resident 105 stated that the hospital inserted the PICC line on 10/25/2022 and the dressing had not been changed since. Resident 105 stated that the dressing was already coming off. Observed a medication bottle name Triumeq at bedside. Resident 105 stated that he had been keeping the medication at his bedside since he was admitted on October because the facility does not carry the medication and that the medication was very expensive.
During an interview on 11/18/2022 at 8:01 p.m., with Assistant Director of Nursing (ADON), stated that the facility's policy about the IV or PICC line is to be changed every seven days and or as needed. ADON stated that the staff was going to change the dressing immediately today. ADON stated that the risk of not changing the dressing was to place resident at risk for further infection.
During a concurrent interview and record review on 11/23/2022 at 11:42 a.m. with Assistant Director of Nursing (ADON), Resident 105's medical chart was reviewed. ADON stated that before allowing resident to have self-administration of medications, the staff need to assess the resident and have doctor's order for the self-administration, and it should also in the care plan. ADON stated there was no care plan for self-administration of medication for Resident 105. ADON further stated that Resident 105 care plan for antibiotic use and IV care was initiated on 11/19/2022. ADON stated that care plan should have been updated or initiated upon admission.
A review of facility's policy and procedures titled Care Plans, Comprehensive Person-Centered with revised date of 12/2016, 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
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.A review of Resident 209's admission Record indicated Resident 209 was admitted into the facility on 9/30/2022 and readmitted ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.A review of Resident 209's admission Record indicated Resident 209 was admitted into the facility on 9/30/2022 and readmitted on [DATE], with diagnoses that included, heart failure (a progressive condition that affects the pumping power of the heart muscle), atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), and insomnia (inability to sleep).
A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/3/2022, indicated Resident 209's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were severely impaired and required extensive assistance from staff for activities of daily livings (ADLs- bed mobility, dressing, and personal hygiene).
A record review of Resident 209's physician's orders indicated the following:
i. Lidocaine (medication for pain management) External Patch 5% - Apply to neck topically one time a day for pain management, ordered on 11/1/2022
ii. Acetaminophen (medication used to treat mild to moderate pain) tablet 325 milligram (mg) - give 1 tablet by mouth every 6 hours as needed (prn) for pain 1-5/10, ordered on 10/3/2022
iii. Acetaminophen tablet 325 mg - give 2 tablet by mouth every 6 hours prn for pain 6-10, ordered on 10/3/2022
iv. Monitor pain every shift by asking how's your pain? scale 1-10 every shift, ordered on 11/1/2022.
A record review of Resident 209's Care Plan for at risk for acute and/or chronic pain brought about by damage to bones, joints, muscles . initiated on 10/18/2022, indicated an intervention assess for pain or pain cues like facial grimacing, discomfort every shift or as needed and medication as ordered.
During a concurrent interview and medication pass observation with Licensed Vocational Nurse 3 (LVN 3) on 11/19/2022 at 8:51 a.m., LVN 3 administered Lidocaine patch to Resident 209 without asking what his pain level with a scale of 1-10 (0 means no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain). LVN 3 did not assesse Resident 209's pain level prior to administering Lidocaine patch. LVN 3 stated she usually puts a 3-4 pain scale which was according to Resident's facial expression.
During an interview with Resident 209 with LVN 3 present in the room on 11/19/2022 at 9:10 a.m., Resident 209 stated he had pain on his neck and his pain level was 9. LVN 3 then stated she should have asked Resident 209 what his pain level was prior to administering pain medication, Lidocaine. LVN 3 further stated, It should have not been up to her to document's residents pain level. LVN 3 further stated, if residents are not assessed correctly what their pain level is, they won't be able to administer the correct pain medications regimen.
During an interview with Assistant Director of Nursing (ADON), on 11/19/2022 at 12:10 a.m., the ADON stated residents should be assessed by asking what their pain level is according to physician's order, such as prior to giving medication. The ADON further stated, if residents are not properly assessed, their pain level will not be properly managed.
A review of the facility's P&P titled, Pain Assessment and Management, revised in March 2020, indicated, during the comprehensive pain assessment, gather the following information as indicated from the resident: characteristics of pain: location of pain, intensity of pain as measured on a s standardized pain scale, characteristics of pain, patter of pain and frequency, timing and duration of pain. The policy further indicated document the resident's reported level of pain with adequate detail (enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program.
Based on observation, interview and record review, the facility failed to meet professional standards of practice by failing to:
1. Ensure proper monitoring and documentation of temperature and oxygen levels (SPO2) and COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) signs and symptoms (s/sx) for residents who are confirmed positive with COVID-19 every four hours per physician order for 12 of 12 residents (Residents 3, 38, 40, 43, 153, 154, 155, 156, 157, 158, 159 and 160).
2. Ensure a pain assessment was completed prior to administering Lidocaine (medication used for relief of neuropathic [nerve] pain) with multiple orders for one of five sampled residents (Resident 209).
These deficient practices had the potential to jeopardized Residents 3, 38, 40, 43, 153, 154, 155, 156, 157, 158, 159 and 160's health and safety by improperly monitoring COVID-19 symptoms and had the potential to result in ineffective pain control and overmedicating Resident 209.
Findings:
1a. A review of Resident 3's admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including infection on right knee prosthesis (artificial device that replaces a missing body part), osteomyelitis (bone infection) and hypertension (HTN - elevated blood pressure).
A review of Resident 3's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/20/2022, indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was intact and required limited assistance from staff for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene).
A review of Resident 3's laboratory test result dated 11/15/2022, indicated Resident 3 was confirmed positive for COVID-19.
A review of Resident 3's Physician order dated 11/14/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 3's physician order also indicated monitoring for s/sx of COVID-19 and document for fever (temperature 100 degree or above), shortness of breath (SOB), etc. every four hours.
A review of Resident 3's vitals summary report indicated some missing oxygen levels and temperature monitoring and documentation every four hours from 11/18/2022 to 11/19/2022.
A review of Resident 3's care plan, dated 11/14/2022, indicated at risk for worsening s/sx of infection due to COVID-19 and with interventions to monitor vital signs (VS) and O2 levels as ordered and/or per Centers for Disease Control and Prevention (CDC) guidance.
1b. A review of Resident 38's admission Record indicated that Resident 38 was admitted in the facility on 10/12/2022, with diagnoses including [NAME] Nile virus infection (WNV-infection transmitted by the bite of an infected mosquito), metabolic 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) and abnormalities of gait and mobility.
A review of Resident 38's MDS, dated [DATE], indicated Resident 38 was cognitively impaired, and requiring extensive assistance with ADLs.
A review of Resident 38's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 38's Physician order dated 11/11/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 38's physician order also indicated monitoring for s/sx of COVID-19 and document for fever, SOB, etc. every four hours.
A review of Resident 38's vitals summary report indicated some missing oxygen levels and temperature monitoring and documentation every four hours from 11/18/2022 to 11/19/2022.
A review of Resident 38's care plan, dated 11/11/2022, indicated at risk for worsening s/sx of infection due to COVID-19 and with interventions to monitor VS and O2 levels as ordered and/or per CDC guidance.
1c. A review of Resident 40's admission Record indicated the facility admitted Resident 40 on 10/17/2022 with diagnoses including neoplasm (a new and abnormal growth of tissues) of bone, brain, liver and lungs, HTN and difficulty in walking.
A review of Resident 40's MDS, dated [DATE], indicated Resident 40's cognitive skills for daily decision-making were intact and required extensive assistance from staff for ADLs.
A review of Resident 40's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 40's Physician order dated 11/11/2022, indicated Resident 40 had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 40's physician order, dated 11/15/2022, also indicated monitoring for s/sx of COVID-19 and document for fever, SOB, etc. every four hours.
A review of Resident 40's vitals summary report indicated some missing oxygen levels and temperature monitoring and documentation every four hours from 11/18/2022 to 11/19/2022.
A review of Resident 40's care plan, dated 11/11/2022, indicated at risk for worsening s/sx of infection due to COVID-19 and with interventions to monitor VS and O2 levels as ordered and/or per CDC guidance.
1d. A review of Resident 43's admission Record indicated that the facility admitted Resident 43 on 10/25/2022 with diagnoses including left knee joint replacement (joint is preplaced by a prosthetic implant [artificial device that replaces a missing body part]) surgery, hyperlipidemia (abnormally high levels of fats in the blood) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure).
A review of Resident 43's MDS, dated [DATE], indicated Resident 43's cognitive skills for daily decision-making were intact and required supervision to limited assistance from staff for ADLs.
A review of Resident 43's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 43's Physician order dated 11/14/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 43's physician order, also indicated monitoring for s/sx of COVID-19 and document for fever, SOB, etc. every four hours.
A review of Resident 43's vitals summary report indicated some missing oxygen levels and temperature monitoring and documentation every four hours from 11/18/2022 to 11/19/2022.
A review of Resident 43's care plan, dated 11/14/2022, indicated at risk for worsening s/sx of infection due to COVID-19 and with interventions to monitor VS and O2 levels as ordered and/or per CDC guidance.
1e. A review of Resident 153's admission Record indicated the facility admitted Resident 153 on 11/18/2022 with diagnoses including right hip replacement surgery, HTN and difficulty in walking.
A review of the MDS, dated [DATE], indicated Resident 153's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 153's laboratory test result dated 11/18/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 153's Physician order dated 11/18/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 153's physician order, also indicated monitoring for s/sx of COVID-19 and document for fever, SOB, etc. every four hours.
A review of Resident 153's vitals summary report indicated some missing oxygen levels and temperature monitoring and documentation every four hours from 11/18/2022 to 11/19/2022.
A review of Resident 153's care plan, dated 11/18/2022, indicated at risk for worsening s/sx of infection due to COVID-19 and with interventions to monitor VS and O2 levels as ordered and/or per CDC guidance.
1f. A review of Resident 154's admission Record indicated the facility admitted Resident 154 on 11/2/2022 with diagnoses including syncope (fainting) and collapse, and gastroesophageal reflux disease (GERD-a digestive disease in which stomach acid irritates the flood pipe lining).
A review of the MDS dated [DATE], indicated Resident 154's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 154's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 154's Physician order dated 11/11/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 154's physician order, also indicated monitoring for s/sx of COVID-19 and document for fever, SOB, etc. every four hours.
A review of Resident 154's vitals summary report indicated some missing oxygen levels and temperature monitoring and documentation every four hours from 11/18/2022 to 11/19/2022.
A review of Resident 154's care plan, dated 11/11/2022, indicated at risk for worsening s/sx of infection due to COVID-19 and with interventions to monitor VS and O2 levels as ordered and/or per CDC guidance.
1g. A review of Resident 155's admission Record indicated that the facility admitted Resident 155 on 11/12/2022 with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), urinary tract infection (UTI-infection in the urinary system [kidneys, bladder, or urethra]) and congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should)
A review of Resident 155's MDS, dated [DATE], indicated Resident 155's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 155's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 155's Physician order dated 11/18/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 155's physician order, also indicated monitoring for s/sx of COVID-19 and document for fever, SOB, etc. every four hours.
A review of Resident 155's vitals summary report indicated some missing oxygen levels and temperature monitoring and documentation every four hours from 11/18/2022 to 11/19/2022.
A review of Resident 155's care plan, dated 11/18/2022, indicated at risk for worsening s/sx of infection due to COVID-19 and with interventions to monitor VS and O2 levels as ordered and/or per CDC guidance.
1h. A review of Resident 156's admission Record indicated Resident 156 was originally admitted to the facility 9/29/2021 and re-admitted on [DATE], with diagnoses including CHF, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose])
A review of Resident 156's MDS, dated [DATE], indicated Resident 156's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 156's laboratory test result dated 11/18/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 156's Physician order dated 11/18/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 156's physician order, also indicated monitoring for s/sx of COVID-19 and document for fever, SOB, etc. every four hours.
A review of Resident 156's vitals summary report indicated some missing oxygen levels and temperature monitoring and documentation every four hours from 11/18/2022 to 11/19/2022.
A review of Resident 156's care plan, dated 11/18/2022, indicated at risk for worsening s/sx of infection due to COVID-19 and with interventions to monitor VS and O2 levels as ordered and/or per CDC guidance.
1i. A review of Resident 157's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including left knee replacement surgery, hyperlipidemia, and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing).
A review of Resident 157's MDS, dated [DATE], indicated Resident 157's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 157's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 157's Physician order dated 11/14/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 157's physician order, dated 11/15/2022 , also indicated monitoring for s/sx of COVID-19 and document for fever, SOB, etc. every four hours.
A review of Resident 157's vitals summary report indicated some missing oxygen levels and temperature monitoring and documentation every four hours from 11/18/2022 to 11/19/2022.
A review of Resident 157's care plan, dated 11/14/2022, indicated at risk for worsening s/sx of infection due to COVID-19 and with interventions to monitor VS and O2 levels as ordered and/or per CDC guidance.
1j. A review of Resident 158's admission Record indicated Resident 158 was admitted to the facility on [DATE], with diagnoses including DM, hyperlipidemia and chronic kidney disease.
A review of Resident 158's MDS, dated [DATE], indicated Resident 158's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 158's laboratory test result dated 11/18/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 158's Physician order dated 11/18/2022, indicated Resident 158 had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 158's physician order, also indicated monitoring for s/sx of COVID-19 and document for fever, SOB, etc. every four hours.
A review of Resident 158's vitals summary report indicated some missing oxygen levels and temperature monitoring and documentation every four hours from 11/18/2022 to 11/19/2022.
A review of Resident 158's care plan, dated 11/18/2022, indicated at risk for worsening s/sx of infection due to COVID-19 and with interventions to monitor VS and O2 levels as ordered and/or per CDC guidance.
During an initial screening on 11/18/2022 at 8:55 p.m., Resident 158 angrily stated that facility staff has not been checking his vital signs since lunch time.
1k. A review of Resident 159's admission Record indicated Resident 159 was admitted to the facility on [DATE], with diagnoses including left knee joint replacement surgery, HTN and COPD.
A review of Resident 159's MDS, dated [DATE], indicated Resident 159's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 159's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 159's Physician order dated 11/15/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 159's physician order, also indicated monitoring for s/sx of COVID-19 and document for fever, SOB, etc. every four hours.
A review of Resident 159's vitals summary report indicated some missing oxygen levels and temperature monitoring and documentation every four hours from 11/18/2022 to 11/19/2022.
A review of Resident 159's care plan, dated 11/14/2022, indicated at risk for worsening s/sx of infection due to COVID-19 and with interventions to monitor VS and O2 levels as ordered and/or per CDC guidance.
1l. A review of Resident 160's admission Record indicated Resident 160 was admitted to the facility on [DATE], with diagnoses including syncope and collapse, CKD and hyperlipidemia.
A review of Resident 160's MDS, dated [DATE], indicated Resident 160's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 160's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19.
A review of Resident 160's Physician order dated 11/15/2022, indicated resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 160's physician order, also indicated monitoring for s/sx of COVID-19 and document for fever, SOB, etc. every four hours.
A review of Resident 160's vitals summary report indicated some missing oxygen levels and temperature monitoring and documentation every four hours from 11/18/2022 to 11/19/2022.
A review of Resident 160's care plan, dated 11/13/2022, indicated at risk for worsening s/sx of infection due to COVID-19 and with interventions to monitor VS and O2 levels as ordered and/or per CDC guidance.
During a concurrent record review and interview with the Assistant Director of Nursing (ADON), on 11/23/2022 at 12:06 p.m., the ADON verified and stated that Residents 3, 38, 40, 43, 153, 154, 155, 156, 157, 158, 159 and 160 were missing some O2 and temperature documentation every 4 hours per physician order. The ADON stated that if it was not documented, it was not done. The ADON stated that it was important to monitor COVID-19 s/sx and including checking vital signs and should be documented.
A review of the facility's policy and procedures (P&P), titled, COVID-19 Facility Mitigation Management Plan, updated 1/14/2022, indicated that all residents with suspected respiratory or infectious illness are assessed (including documentation of temperature, respiratory rate and oxygen saturation) at least twice a shift to quickly identify residents who require transfer to a higher level of care and must be documented in the clinical records.
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, the facility failed to ensure a resident's peripherally inserted central cat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's peripherally inserted central catheter (PICC, also called a PICC line, is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart, It's generally used to give medications or liquid nutrition) dressing was changed as indicated in the facility's policy for five of five sampled residents (Residents 19, 207, 208, 15 and 105).
This deficient practice had the potential for an increased risk of infection to Residents 19, 207, 208, 15 and 105'S peripheral catheter insertion site.
Findings:
1. A review of Resident 19's admission Record indicated the facility admitted Resident 19 on 9/16/2022 and readmitted on [DATE] with diagnoses including cellulitis (a potentially serious bacterial skin infection), chronic respiratory failure with hypoxia (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and hypertension (HTN - elevated blood pressure).
A review of Resident 19's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/7/2022, indicated Resident 19's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required extensive assistance from staff for activities of daily livings (ADLs- transfer, dressing toilet use, and personal hygiene).
A review of Resident 19's Medication Administration Record (MAR) for the month October 2022, indicated Resident 19 was on Meropenem (an injection used to treat skin and abdominal [stomach area] infections caused by bacteria and meningitis (infection of the membranes that surround the brain and spinal cord) in adults and children 3 months of age and older), every eight hours for pneumonia (an infection in one or both lungs).
During an observation of Resident 19 on 11/18/2022 at 8:30 p.m., Resident 19 was observed with a PICC line with a gauze and dressing taped and dated 11/12/2022. Resident 17 stated, she does not remember when the PICC line dressing was last changed.
During a concurrent interview and observation of Resident 19 with Registered Nurse 1 (RN 1), on 11/18/2022 at 8:34 p.m., RN 1 confirmed and stated, the PICC line dressing had a gauze and was dated 11/12/2022. RN 1 stated, PICC line with gauze should be changed every two days to prevent infection in the intravenous (IV) catheter line site.
2. A review of Resident 207's admission Record indicated the facility admitted Resident 207 on 11/06/2022 with diagnoses including COVID-19 (coronavirus - an infectious disease that can cause respiratory illness in humans), sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and metabolic encephalopathy (a chemical imbalance in the blood affecting the brain).
A review of Resident 207's MDS dated [DATE], indicated Resident 207's cognitive skills for daily decision-making were intact and required extensive assistance from staff for ADLs- transfer, dressing, toilet use, and personal hygiene.
During an observation of Resident 207's on 11/18/2022 at 8:33 p.m., observed Resident 207 with an IV-line access, the transparent dressing was soiled with dried red-looking blood was observed in the dressing and the dressing was dated 11/02/2022. Resident 207 stated, it has not been changed since he got admitted and the IV line was started from acute care hospital.
During an interview with RN 1 on 11/18/2022 at 8:40 p.m., RN 1 stated and confirmed the IV access line dressing was already soiled and needed to be changed as the date on the IV dressing was 11/2/2022.
3. A review of Resident 208's admission Record indicated the facility admitted Resident 208 on 11/02/2022 with diagnoses including Parkinson's disease (a disorder in the brain that affects movement, often including tremors), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and HTN.
A review of the MDS dated [DATE], indicated Resident 208's cognitive skills for daily decision-making were moderately intact and required limited assistance from staff for ADLs- transfer, toilet use, and personal hygiene.
During an observation and interview with Resident 208 on 11/18/2022 at 6:50 p.m., Resident 208 is connected to IV-line tubing with no label of date and time when it was hung. Resident 208 IV-line access dressing does not have any label of date and time when it was last changed. Resident 208 stated, she is receiving hydration through her IV line and does not remember when the dressing was last changed.
During a concurrent observation and interview with Director Of Nursing (DON), on 11/18/22 at 10:34 p.m., DON stated the IV-line access dressing and the IV tubing does not have any date. DON stated, it should have been dated as the IV-line access needs to be changed every 7 days and the IV tubing needs to be changed as well.
A review of facility's policy and procedures (P&P), titled Guidelines for Preventing Intravenous Catheter-Related Infections, revised on August 2014 indicated, Change continuous primary and secondary administration sets (used for fluids other than blood, blood products, or lipids) no more frequently than every 96 hours, unless there is suspected contamination, or when integrity of the product or system has been compromised.
4. A review of Resident 15's admission Record indicated the facility originally admitted Resident 15 on 2/24/2022 and readmitted on [DATE] with diagnoses including COVID-19 and Type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of the MDS dated [DATE], indicated Resident 15's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs- transfer, dressing, toilet use, and personal hygiene.
A review of Resident 15's laboratory test, collected on 11/15/2022 indicated, Resident 15 was confirmed positive for COVID-19.
During a concurrent observation and interview with Resident 15 on 11/18/2022 at 8:38 p.m. observed Resident 15's IV line dressing was soiled with dried red-looking blood and the dressing is almost coming off, moreover, the IV-line access has no label of date when it was last changed. Resident 15 stated, he used to get hydration via IV and his IV-line dressing has not been changed since admission and he was admitted with it from the hospital.
During a concurrent observation and interview with RN 1 on 11/18/2022 at 8:43 p.m., RN 1 stated, the IV-line dressing should be changed as it doesn't have any date and he doesn't know when it was last changed. RN 1 stated, he will change the dressing tonight.
During an observation of Resident 15 on 11/22/2022 at 12:36 p.m., Resident 15 still had the previous IV-line dressing. Resident 15 stated, they have not changed the dressing.
During a concurrent observation and interview with the Assisitant Director Of Nursing (ADON), on 11/22/2022 at 12: 43 p.m., the ADON stated, Resident 15's IV line dressing is soiled with old blood, ADON stated, she will remove it as Resident 15 is no longer on any IV medications. The ADON stated, if IV-line dressing was not dated, they won't know when it was last changed and when staff assess IV line dressing is soiled, they need to change it to prevent infection to the IV site.
5. A review of Resident 105's admission Record indicated the facility admitted the
resident on 10/28/2022, with diagnoses including osteomyelitis (infection of the bone), Human immunodeficiency virus (HIV-causes AIDS and interferes with the body's ability to fight infections) disease and Kaposi's sarcoma (skin cancer).
A review of Resident 105's MDS, dated [DATE], indicated Resident 105 was alert and able to verbalize needs. MDS also indicated that the resident was getting an antibiotic via intravenously.
A review of Resident 105's Physician order dated 11/7/2022 indicated an order of Cefepime (antibiotic) hydrochloride two gram/100 milliliter, use two grams intravenously every 12 hours for osteomyelitis until 12/19/2022.
A review of Resident 105's Physician order dated 10/28/2022 indicated an order Cubicin (antibiotic) solution use 500 milligram (mg) intravenously every 24 hours for osteomyelitis until 12/19/2022.
A review of Resident 105's Care plan initiated on 11/19/2021, indicated Resident 105 needs IV (intravenously) therapy due to osteomyelitis. One of the interventions was to change IV site, dressing, tubing, solution container per protocol and tape IV catheter and tubing securely.
A review of Resident 105's Intravenous Medication record for the month of November 2022, indicated that the Registered Nurse 2 (RN 2) changed the IV dressing on 11/5/2022, 11/12/2022 and 11/19/2022.
During a concurrent interview and observation with Resident 105 on 11/18/2022 at 7:12 p.m , inside the room. Resident 105 was observed with a PICC line on right antecubital area. Resident 105 stated that the hospital inserted the PICC line on 10/25/2022 and the dressing had not been changed since. Resident 105 stated that the dressing was already coming off.
During an interview with the ADON, on 11/18/2022 at 8:01 p.m., the ADON stated the facility's policy about the IV or PICC line was to be changed every seven days and or as needed. The ADON further stated the risk of not changing the dressing was to place resident at risk for further infection.
During a concurrent interview and record review on 11/22/22 at 12:30 p.m. with RN 2, Resident 105's IV MAR was reviewed. RN 2 stated for IV dressing change, she would document it under change IV dressing and injection cap. RN 2 stated she documented in the MAR on 11/5/2022, 11/12/2022 and 11/19/2022 but did not remember if she changed the IV dressing for Resident 105. RN 2 further stated she should not be documenting in the MAR if she did not do the procedure. RN 2 further stated the risk of documenting that the dressing change was done even if she did not was the dressing change will not be done per the facility's policy and procedures.
A review of the facility's P&P titled Central Venous Catheter Dressing Changes, revised on April 2016 indicated, the purpose of this procedure is to prevent catheter-related infections that are associated with contaminated loosened, soiled, or wet dressings .change transparent semi-permeable membrane (TSM) dressing at least every 5-7 days and as needed, when wet, soiled or not intact, if gauze is used, it must be changed every two 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** Based on observation, interview and record review, the facility failed to ensure the respiratory care was consistent with profes...
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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 respiratory care was consistent with professional standards of practice to meet the resident's goal for four of four sampled residents (Residents 19, 10, 12 and 101) by failing to ensure Residents 19, 10, 12 and 101's oxygen nasal cannula (NC- device used to deliver supplemental oxygen or increased airflow to a patient or person in need of oxygen) was changed on a weekly basis and not touching the floor.
This deficeint practice had the potential to contribute to an increased risk of infection and decrease the effectiveness of medication ordered by the physician.
Findings:
A. A review of Resident 19's admission Record indicated the facility admitted Resident 19 on 9/16/2022 and readmitted on [DATE] with diagnoses including cellulitis (a potentially serious bacterial skin infection), chronic respiratory failure with hypoxia (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and hypertension (HTN - elevated blood pressure).
A review of Resident 19's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/7/2022, indicated Resident 19's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required extensive assistance from staff for activities of daily livings (ADLs- transfer, dressing toilet use, and personal hygiene).
A review of Resident 19's Physician order dated 10/4/2022, indicated Resident 19 had an order for oxygen via NC at four liters per minute continuously every shift.
During an observation of Resident 19 on 11/18/2022 at 8:30 p.m., Resident 19 was observed on oxygen therapy via NC, the NC tubing was touching the floor and it does not have any label of date when it was last changed. Resident 17 stated, she doesn't remember when the last NC tubing was changed.
During a concurrent interview and observation of Resident 19 with Registered Nurse 1 (RN 1) on 11/18/2022 at 8:34 p.m., RN 1 confirmed and stated, the NC tubing was touching the floor and it should be properly dated of when it was last changed. RN 1 stated, NC should be changed every week or as needed. RN 1 further stated, it shouldn't be touching the floor as well as puts resident at risk of infection.
B. A review of Resident 10's admission Record indicated the facility admitted Resident 10 on 2/13/2020 and readmitted on [DATE] with diagnoses including chronic respiratory failure, chronic obstructive pulmonary (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and Type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of the MDS dated [DATE], indicated Resident 10's cognitive skills for daily decision-making were moderately intact and required limited assistance from staff for ADLs- transfer, toilet use, and personal hygiene.
A review of Resident 10's Physician order dated 10/3/2022, indicated resident had an order for continuous oxygen inhalation at two liters per minute via NC to keep O2 saturation more than or equal to 92%.
During a concurrent observation and interview with Resident 10 on 11/18/2022 at 7:59 p.m., Resident 10 was on Oxygen NC with the NC tubing touching the floor, soiled, and was dated 10/19/2022. Resident 10 stated she needs to be on oxygen because she has shortness of breath. Resident 10 stated, she doesn't remember when the NC tubing it was last changed at all.
During an interview with RN 1 on 11/18/2022 at 8:57 p.m., RN 1 stated and confirmed, Resident 10's NC tubing was touching the floor and was dated 10/19/2022. RN 1 stated, it should have been changed once a week or as needed. RN 1 stated, he will change the NC tubing as it's been more than a month ago and are already murky (dark and gloomy, especially due to thick mist).
During a follow-up observation of Resident 10 on 11/21/2022 at 12:49 p.m., Resident 10's NC tubing is still dated 10/19/2022 and the NC tubing has some dark stained.
During a concurrent observation and interview with Registered Nurse 4 (RN 4) on 11/21/2022 at 12:57 p.m., RN 4 stated and confirmed, Resident 10's NC tubing is dated 10/19/2022. RN 4 stated, the NC tubing should have been changed once a week or as needed. RN 4 stated, she will change the tubing as soon as possible.
During an interview with Infection Preventionist (IPN) on 11/9/2022 at 9:51 a.m., IPN stated NC tubing shouldn't be touching the floor and it should be changed once a week or as needed to prevent infection. IPN stated she will do an in-service to the staffs regarding the proper practice of oxygen NC tubing.
A review of facility's P&P titled, Respiratory Therapy - Prevention of Infection, revised in October 2019 indicated, change the oxygen cannula and tubing every seven days or as needed.
C. A review of Resident 12's admission Record indicated the facility admitted Resident 12 on 6/17/2022 with diagnoses including heart failure (heart does not pump blood as well as it should), pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of right and left heel and chronic respiratory failure with hypoxia (low oxygen level).
A review of Resident 12's history and physical dated 8/8/2022, indicated resident does not have the capacity to understand and make decision.
A review of Resident 12's Physician order dated 8/4/2022, indicated resident had an order for oxygen via nasal cannula at one to two liters per minute as needed to keep oxygen saturation greater than or equal to 93%.
During a concurrent observation and interview with Family member 1 (FM 1) and Certified Nursing Assistant 1 (CNA 1), on 11/18/2022 at 6:50 p.m. inside Resident 12's room, nasal cannula tubing was observed touching the floor and there was no date on when it was last changed. CNA 1 took off the nasal cannula tubing from the floor.
During a concurrent observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 11/18/2022 at 7:00 p.m. resident 12's nasal cannula was observed. LVN 1 stated that there was no date on when the nasal cannula tubing was changed and should be change every seven days.
E. A review of Resident 101's admission Record indicated the facility admitted Resident 101 on 11/14/2022 with diagnoses including chronic respiratory failure with hypoxia, asthma (condition in which person's airway become inflamed causing difficulty in breathing) and diabetes (disease that results in too much sugar in the blood).
A review of Resident 101's MDS, dated [DATE], indicated the resident's cognition was intact.
A review of Resident 101's Physician order dated 11/14/2022, indicated resident had an order for oxygen via nasal cannula at one liter per minute continuously every shift to maintain oxygen saturation at greater than 90%.
During a concurrent observation and interview on 11/18/2022 at 7:09 p.m. with Certified Nursing Assistant 10 (CNA 10), inside resident 101's room. CNA 10 observed the nasal cannula tubing was touching the floor. CNA 10 observed taking the nasal cannula tubing off the floor and stated it should not touch the floor.
A review of facility's P&P titled, Respiratory Therapy - Prevention of Infection, revised in October 2019 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 F0697
(Tag F0697)
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 effective pain management by failing to document the pain as...
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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 effective pain management by failing to document the pain assessments and to offer nonpharmacological intervention prior to pharmacological intervention for two out of two sampled residents investigated under the care area of pain management (Resident 100 and Resident 209) by failing to ensure:
1. Resident 100 had a care plan regarding pain management.
2. Resident 100 had an accurate documentation of the Oxycodone hydrochloride (narcotic pain medication) in the electronic Medication Administration record (eMAR).
3. Resident 100 was offered nonpharmacological interventions for pain management.
4. Resident 209 was assessed for pain level during the medication administration.
These deficient practices had the potential to result in ineffective pain control as well as potential for overmedicating and under medicating the residents.
Cross reference to F755 and F656
Findings:
1. A review of Resident 100's admission Record (facesheet) indicated the facility admitted the resident on 11/15/2022 with diagnosis including multiple fractures of pelvis, compression fracture of thoracic (spine located in the upper and middle part of the back) and lumbar (bones in the lower back) area and depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
A review of Resident 100's History and Physical (H&P) dated 11/15/2022, indicated resident has the capacity to understand and make decisions.
A review of Resident 100's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 11/21/2022, indicated Resident 100 was alert and able to verbalize needs. MDS also indicated that the resident received as needed pain medications and received non-medication interventions for pain. It also indicated that resident had pain almost constantly and made it hard for the resident to sleep at night and limited the day-to-day activities because of the pain.
A review of Resident 100's physician order dated 11/15/2022 indicated resident had an order for oxycodone hydrochloride (narcotic pain medication) 10 milligram (mg) give one tablet by mouth every four hours as needed for severe pain.
A review of Resident 100's physician order dated 11/18/2022, indicated resident had an order for dilaudid (narcotic pain medication) two milligram by mouth, give one tablet by mouth as needed for pain management three times a day.
During an interview on 11/18/2022 at 7:50 p.m., Resident 100 stated that his pain is unbearable sometimes and they had been giving him pain medications but was not enough sometimes. Resident 100 denied having any non-pharmacological interventions provided by the staff in the facility.
During a concurrent interview and record review on 11/22/2022 at 5:30 p.m., with Assistant Director of Nursing (ADON), Resident 100's medical chart was reviewed. ADON stated that there was no baseline or comprehensive care plan for resident regarding pain medication or pain assessment. ADON stated that the resident needed a care plan for pain because of his diagnosis. ADON stated that the resident was place at risk for unresolved pain.
2. A review of Resident 100's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 11/21/2022, indicated Resident 100 was alert and able to verbalize needs. MDS also indicated that the resident received as needed pain medications and received non-medication interventions for pain. It also indicated that resident had pain almost constantly and made it hard for the resident to sleep at night and limited the day-to-day activities because of the pain.
A review of Resident 100's Physician Order dated 11/15/2022 indicated resident had an order for oxycodone (narcotic pain medication) hydrochloride (hcl) 10 milligram (mg) give one tablet by mouth every four hours as needed for severe pain.
A review of Resident 100's Controlled Medication Count Sheet for Oxycodone 10 mg tablet indicated that the medication were removed on the following day:
11/16/2022 at 5:35 a.m.
11/16/2022 at 9:40 a.m.
11/16/2022 at 2:48 p.m.
11/16/2022 at 8:00pm
11/17/2022 at 12:18 a.m.
11/17/2022 at 5:57 a.m.
11/17/2022 2:15 p.m.
11/17/2022 time not legible
11/17/2022 11:25 pm
11/18/2022 at 3:30 a.m.
11/18/2022 at 8:08 a.m.
11/18/2022 12:50 p.m.
11/18/2022 at 4:53 p.m.
11/18/2022 at 9:00 p.m.
11/19/2022 at 1:00 a.m.
11/19/2022 at 5:00 a.m.
11/19/2022 at 9:30 a.m.
11/19/2022 at 2:32 p.m.
11/19/2022 at 6:30 p.m.
11/20/2022 at 510 a.m.
A review of Resident 100's Medication Administration record for November 2022, indicated oxycodone 10 mg was administered on these days:
11/16/2022 at 12:04 a.m.
11/15/2022 at 5:35 a.m.
11/16/2022 at 9:40 a.m.
11/16/2022 at 2:48 p.m.
11/16/2022 at 7:46 p.m.
11/17/2022 at 12:18 a.m.
11/17/2022 at 5:57 a.m.
11/17/2022 at 2:15 p.m.
11/17/2022 at 11:24 p.m.
11/18/2022 at 3:31 a.m.
11/18/2022 at 8:08 a.m.
11/18/2022 at 12:53 p.m.
11/18/2022 at 4:53 p.m.
11/19/2022 at 9:30 a.m.
11/19/2022 at 12:33 p.m.
11/19/2022 at 6:30 p.m.
11/20/2022 at 5:12 a.m.
During a concurrent observation, interview and record review on 11/20/2022 at 11:29 a.m., with Licensed Vocational Nurse 3 (LVN 3), oxycodone hcl narcotic count for Resident 100 was reviewed. LVN 3 stated that there were total of 20 tablet of oxycodone was removed in the bubble pack. LVN 3 stated that according to the eMAR, there were only 17 doses were documented.
During a concurrent interview and record review on 11/20/2022 at 12:15 p.m., with Assistant Director of Nursing (ADON) the narcotic count and eMAR for oxycodone hcl was reviewed. ADON stated that there were total of four doses of oxycodone that was not accounted for in the eMAR. ADON stated that the first dose on 11/16/2022 at 12:04 a.m. was taken from the emergency medication kit (ekit). ADON further stated that this place resident at risk for under medicating or over medicating the resident with narcotic medication.
A review of the facility's policy and procedure titled Administering Medications with revised date of 4/2019, indicated that the medications are administered [NAME] safe and timely manager and as prescribed. It also indicated that the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. It further stated that as required or indicated for a medication, the individual administering the medication records in the resident's medical record:
1. Date and time the medications were administered
2. The dosage
3. The route of administration .
4. Any results achieved and when those results were observed and signature and title of the persons administering the drug.
A review of Resident 100's Physician Order dated 11/17/2022, indicated resident had an order for pain medication non-pharmacological intervention code as needed:
1. Repositioning
2. Dim light/quiet environment
3. Hot/cold applications
4. Relaxation technique
5. Distraction
6. Music
7. Massage
A review of Resident 100's eMAR for November 2022 indicated that there was no non-pharmacological intervention offered to the resident.
A review of facility's policy and procedure titled Pain Assessment and Management with revised date of 3/2020, indicated that the purpose of this procedure are to help the staff identify pain in the resident, an to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. It also indicated that 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. It also indicated that the non-pharmacological interventions may be appropriate alone or in conjunction with medications. Pharmacological interventions may be prescribed to manage pain, however they do not usually address the cause of pain and can have adverse effects on the resident.
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 observation, interview, and record review, the facility failed to provide sufficient staffing to accommodate 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 provide sufficient staffing to accommodate residents needs by not answering the call light timely for eight of eight sampled residents (Resident 40, 43, 151, 152, 155, 157, 158, and 159).
This deficient practice resulted in residents not receiving needed services timely and efficiently and had the potential to cause falls and injuries affecting the residents' safety and wellbeing.
Findings:
1. A review of Resident 40's admission Record indicated that the facility admitted the resident on 10/17/2022 with diagnoses including neoplasm (a new and abnormal growth of tissues) of bone, brain, liver and lungs, hypertension (HTN-elevated blood pressure) and difficulty in walking.
A review of Resident 40's Minimum Data Set (MDS-a standardized assessment and care-screening tool), dated 10/21/2022, indicated Resident 40's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and the resident required extensive assistance from staff for activities of daily livings (ADLs-bed mobility, dressing, toilet use and personal hygiene).
A review of Resident 40's Physician order dated 11/11/2022, indicated the resident had an order for contact/droplet isolation (steps that healthcare facility visitors and staff need to follow when going into or leaving a resident's room) per facility protocol for COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) monitoring.
A review of Resident 40's fall risk assessment, dated 10/17/2022, indicated that Resident 40 was high risk for fall.
A review of Resident 40's care plan, dated 10/17/2022, indicated that Resident 40 was at risk for fall with interventions to assist the resident with transfers/mobility as needed and to encourage resident to ask for assistance and to have staff do a prompt response to all resident's requests.
During an initial tour and a concurrent interview on 11/18/2022 at 7:38 p.m., Resident 40 stated that staff took a long time answering the call lights and she had to wait for more than half an hour. Resident 40 also stated she felt that, since they tested positive with COVID-19, staff at times did not want to come and see them.
2. A review of Resident 43's admission Record indicated that the facility admitted the resident on 10/25/2022 with diagnoses including left knee joint replacement (joint is preplaced by a prosthetic implant [artificial device that replaces a missing body part]) surgery, hyperlipidemia (abnormally high levels of fats in the blood) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure).
A review of Resident 43's MDS, dated [DATE], indicated Resident 43's cognitive skills for daily decision-making were intact and the resident required supervision to limited assistance from staff for ADLs.
A review of Resident 43's Physician order dated 11/14/2022, indicated the resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring.
A review of Resident 43's care plan, dated 11/9/2022, indicated that Resident 43 was at risk for fall with interventions to have the resident's call light within reach, and to encourage to use for assistance as needed and for staff to answer promptly to all requests.
During an initial tour and a concurrent interview on 11/18/2022 at 8:33 p.m., Resident 43 stated that it took approximately 30 minutes or more for the staff to answer her call light. Resident 43 also stated that since she had been having diarrhea (frequent discharge of feces and usually in liquid form) and was using a commode which needed constant emptying. Resident 43 stated she felt embarrassed since she had a roommate.
3. A review of Resident 151's admission Record indicated that the facility admitted the resident on 11/17/2022 with diagnoses including chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe) and abnormalities of gait and mobility.
A review of Resident 151's MDS, dated [DATE], indicated Resident 151's cognitive skills for daily decision-making were intact and the resident required limited to extensive assistance from staff for ADLs.
A review of Resident 151's Physician order dated 11/22/2022, indicated the resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring. Resident 151's physician order indicated taking bumetanide (treats fluid retention, causing to urinate often) tablet 2 milligrams (mg), two tablets by mouth twice daily.
During an initial tour and interview on 11/18/2022 at 8:33 p.m., Resident 151 stated that call light was the main issue in the facility. Resident 151 stated waiting time was over an hour and she had to call the facility phone so someone could attend her bowel and bladder needs. Resident 151 also stated that she constantly needed to use the bedpan since she took a medication to make her urinate more.
4. A review of Resident 152's admission Record indicated that the facility admitted the resident on 11/3/2022 with diagnoses including left knee replacement) surgery, difficulty in walking and hyperlipidemia.
A review of Resident 152's MDS, dated [DATE], indicated Resident 152's cognitive skills for daily decision-making were intact and the resident required limited assistance from staff for ADLs.
A review of Resident 152's care plan, dated 11/3/2022, indicated Resident 152 was at risk for fall with interventions to have resident's call light within reach, and encourage to use for assistance as needed and for staff to answer promptly to all requests.
During an initial tour on 11/18/2022 at 7:05 p.m., Resident 152's room was observed with call light on, door opened and Resident 152 was about to come out with an empty pitcher. Resident 152 stated that she had been waiting for a fresh water since 5:00 p.m. Resident 152 stated also that she did not want to come out of her room but her call light had not been answered.
5. A review of Resident 155's admission Record indicated that the facility admitted the resident on 11/12/2022 with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), urinary tract infection (UTI-infection in the urinary system [kidneys, bladder, or urethra]) and congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should).
A review of Resident 155's MDS, dated [DATE], indicated Resident 155's cognitive skills for daily decision-making were intact and the resident required limited assistance from staff for ADLs.
A review of Resident 155's Physician order dated 11/18/2022, indicated the resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring.
A review of Resident 155's care plan, dated 11/12/2022, indicated that Resident 155 was at risk for fall with interventions to have resident's call light within reach, assess degree of orientation, vision and safety awareness for safety needs and maintain a safe and hazard free environment.
During an initial tour on 11/18/2022 at 8:20 p.m., Resident 155's room was observed with call light on. Resident 155 stated that she had been waiting for more than an hour for someone to assist her to eat since her personal caregiver could not come and help her due to her (Resident 155) isolation. Resident 155 stated that she had not eaten her dinner and was very hungry.
6. A review of Resident 157's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including left knee replacement surgery, hyperlipidemia and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing).
A review of Resident 157's MDS, dated [DATE], indicated Resident 157's cognitive skills for daily decision-making were intact and the resident required limited assistance from staff for ADLs.
A review of Resident 157's Physician order dated 11/14/2022, indicated the resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring.
A review of Resident 157's care plan, dated 11/9/2022, indicated that Resident 157 was at risk for fall with interventions to have the resident's call light within reach, assess degree of orientation, vision and safety awareness for safety needs and maintain a safe and hazard free environment.
During an initial tour and a concurrent interview on 11/18/2022 at 8:39 p.m., Resident 157 stated that staff took a long time to answer the call light especially during the night when she needed her pain medication so she could sleep.
7. A review of Resident 158's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), hyperlipidemia and chronic kidney disease.
A review of Resident 158's MDS, dated [DATE], indicated Resident 158's cognitive skills for daily decision-making were intact and the resident required limited assistance from staff for ADLs.
A review of Resident 158's Physician order dated 11/18/2022, indicated the resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring.
A review of Resident 158's care plan, dated 11/8/2022, indicated that Resident 158 was at risk for fall with interventions to have the resident's call light within reach, assess degree of orientation, vision and safety awareness for safety needs and maintain a safe and hazard free environment.
During an initial tour on 11/18/2022 at 8:55 p.m., Resident 158's room was observed with call light on. Resident 158 stated that staff never answered his call light and he had to wait more than an hour and a half for staff. Resident 158 stated that he needed someone to check his vital signs but no one had come in since earlier on the day.
8. A review of Resident 159's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including left knee joint replacement surgery, HTN and COPD.
A review of Resident 159's MDS, dated [DATE], indicated Resident 159's cognitive skills for daily decision-making were intact and the resident required limited assistance from staff for ADLs.
A review of Resident 159's Physician order dated 11/14/2022, indicated the resident had an order for contact/droplet isolation per facility protocol for COVID-19 monitoring.
A review of Resident 159's care plan, dated 11/5/2022, indicated that Resident 159 was at risk for fall with interventions to have the resident's call light within reach, assess degree of orientation, vision and safety awareness for safety needs and maintain a safe and hazard free environment.
During an initial tour on 11/18/2022 at 9:01 p.m., Resident 159's room was observed with call light on. Resident 159 stated that Resident 158 was correct about staff response to call lights and that staff took about an hour or more to answer their call requests. Resident 159 also stated that he had to wait for 45 minutes to empty his full urinal and to get fresh water earlier on the day.
During an interview with the Assistant Director of Nursing (ADON) on 11/23/2022 at 3:59 p.m., the ADON stated that call light must be answered right away to be able to attend resident's needs and safety.
A review of the facility's Facility Assessment (FA) 2022, updated on 4/20/2022, indicated that facility staff must have sufficient nursing staff members with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each residents, as determined by the resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required.
A review of the facility's policy and procedure (P&P), titled, Call Light-Answering, undated, indicated that the facility will meet the resident's needs and request within an appropriate time frame since it is the only mechanism at the resident's bedside whereby residents are able to alert nursing personnel to their needs. P&P also indicated to answer all the call lights promptly regardless of whose resident it is.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure:
1. One of two medication carts (med cart 1) was secured under direct observation of authorized staff in an area.
2. A...
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Based on observation, interview and record review, the facility failed to ensure:
1. One of two medication carts (med cart 1) was secured under direct observation of authorized staff in an area.
2. An unopened insulin pen (injectable medication used to treat high blood sugar) was stored in the refrigerator.
3. A date was indicated of when Tuberculin (used in a skin test to help diagnose tuberculosis [TB], a highly contagious infection of the lungs) vials were opened to readily identify when the vial should be discarded.
These deficient practices had the potential to compromise the therapeutic effectiveness of the medication and had the potential for unauthorized access to the medications.
Findings:
1. During an observation on 11/19/2022 at 12:20 p.m., Medication Cart 1 was observed in front of a room unlocked.
During a concurrent observation and interview on 11/19/2022 at 12:25 p.m., Licensed Vocational Nurse 4 (LVN 4), who was in front of the Medication Cart 1, confirmed that the medication cart was unlocked when she was inside her resident's room. LVN 4 stated the medication carts should be secured and locked if not in use.
A review of the facility's policy and procedure titled Security of Medication Cart with revised date of 4/2007, indicated that medication cart shall be secured during medication passes. It also indicated that medication carts must be securely locked at all times when out of nurse's view.
2. During a concurrent observation and interview on 11/18/2022 at 8:21 p.m., with LVN 1, an unused insulin pen (a device used to give an insulin injection) was observed inside a bag with a note refrigerate in medication cart 1. The note in the bag also indicated that insulin pen needs to be refrigerated if unopen. In addition, an open bottle of glucose (blood sugar) strip and an open bottle of glucose solution were observed with no open date.
A review of the blood glucose monitoring system's user guide indicated that it is important to check the expiration date printed on the test strip bottle. The guide also indicated to record the date opened on the bottle label and to discard the bottle and any remaining test strip after six months from date of opening.
A review of the facility's policy and procedure titled storage of medications with revised date of 4/2007, indicated that the facility shall store all drugs and biologicals in a safe, secure and orderly manner. It also indicated that medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurses' station or other secured location.
3. During a concurrent observation and interview on 11/18/2022 at 8:41 p.m., with Assistant Director of Nurse (ADON), medication refrigerator 1 was observed. Two open tuberculin solution vials were observed with no open date. The ADON stated that the vials should have been labeled with date once opened.
A review of the facility's policy and procedure titled Administering medications with revised date of 4/2019, indicated that the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.
A review of the tuberculin manufacturer's guidelines indicated that a vial of tuberculin which has been entered and in use for 30 days should be discarded.
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 in the kitchen when food items were kept beyond the use-by-date in the refrigerator.
T...
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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage in the kitchen when food items were kept beyond the use-by-date in the refrigerator.
This deficient practice had the potential to result in compromised food qualities, harmful bacteria growth and cross contamination that could lead to foodborne illness in 48 out of 48 residents who received food and water from the kitchen.
Findings:
During a concurrent observation and interview on 11/18/2022 at 6:05 p.m., with Dietary Aide 1 (DA 1), a tuna salad in a Tupperware was observed with date made on 11/14/2022 and use by date of 11/17/2022. Three (3) tubs of margarine were also observed with open date of 10/6/2022 and use by date of 11/6/2022. DA 1 stated that the food items kept beyond the use-by-date should have been thrown away.
During an interview on 11/19/2022 at 11:19 a.m., with Dietary Supervisor (DS), the DS stated that all food should be thrown away after the use by date indicated in the label.
A review of the facility's policy and procedure titled Procedure for refrigerated storage indicated that all refrigerated foods are to be kept the amount of time per refrigerated storage guidelines.
A review of the 2017 U.S. Food and drug Administration Food Code indicated that for time temperature controlled for safety (TCS) food made on the premises and held more than 24 hours the food is to be marked to indicate the date or day it is to be consumed or discarded. It also indicated that for commercially prepared, refrigerated, ready-to-eat TCS food, the food is to be marked with the time the container is opened. If the food will be held for more than 24 hours, it is to indicate the date or day it will be consumed or discarded.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to monitor Residents' personal foods that were placed in a Residents' refrigerator. There were multiple food/drinks inside the R...
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Based on observation, interview, and record review, the facility failed to monitor Residents' personal foods that were placed in a Residents' refrigerator. There were multiple food/drinks inside the Residents' refrigerator brought by the family that did not have a name or date when it was opened.
These deficient practices had the potential to result in food-borne illness and compromised infection control for all residents who received food from outside sources.
Findings:
During an observation on 11/18/2022 at 6:20 p.m., the Residents Refrigerator was observed inside the employee's break room. Signs posted that the fridge will be cleaned daily every morning. The sign also indicated that any items with no date or name will be discarded.
During a concurrent observation and an interview on 11/19/2022 at 6:27 p.m. with Certified Nursing Assistant 1 (CNA 1), the Residents' Refrigerator was observed. There was an open milk shake, boost and organic chocolate milk bottle observed with no label on when it was opened. Observed a mashed potato soup with date 11/15/2022. Observed a plastic container with watermelon inside with no open date. Observed a brown bag, inside there were a container with soup, rye bread and a matzo ball, no date observed. observed a halvah cheese, with only a room number but no date. CNA 1 stated the housekeeper maintained the Residents' Refrigerator and that all food brought by the family from outside should have a name and date. CNA1 further stated the milk shakes and any bottled drinks should have a name of the resident and date when it was opened.
During a concurrent observation and an interview on 11/20/2022 at 9:01 a.m., with Housekeeper/Maintenance Supervisor (MS) Residents' refrigerator was observed. MS stated that all food brought from outside should have a date and name of the resident. MS further stated that the food was only good for two days and it should be discarded.
A review of the facility's undated policy and procedures titled Food for residents from outside sources, indicted food brought in from outside the facility kitchen for resident's consumption will be monitored. The same policy also indicated that prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, nursing station's refrigerator or in the residents' personal refrigerator. In the food service department, the policy on food storage will apply. Otherwise, if unopened, refrigerated, or frozen items will be disposed of by the expiration date on the container. If opened, the food must be sealed, dated to the date opened and disposed of in three days after opening.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for five out of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for five out of five sampled residents (Resident 3, 99, 105, 150, and 157).
This deficient practice had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.
Findings:
1. A review of Resident 3's admission Record indicated resident was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including infection of the right knee prosthesis (artificial device that replaces a missing body part), following a surgery, osteomyelitis (bone infection) and hypertension (HTN-elevated blood pressure).
A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/20/2022, indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required limited assistance from staff for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene).
A record review of Resident 3's Order Summary Report, dated 10/21/2022, indicated that Resident 3 had an order for a ceftriaxone sodium (antibiotic /anti-bacterial medicine) 2 grams (gm) via intravenous (IV-administering fluid medication through a needle or tube inserted into a vein) once a day for knee infection.
A review of Resident 3's chart, indicated missing documentation for the facility's antibiotic stewardship monitoring.
During a concurrent record review and interview with the Infection Preventionist Nurse (IPN) on 11/20/202 at 12:01 p.m., IPN stated and verified, not being able to do the antibiotic stewardship. IPN stated that antibiotic stewardship monitoring was supposed to be done when a resident gets an order to start an antibiotic. IPN also stated that she was supposed to collaborate with the team to monitor appropriate use of antibiotics to the resident.
During an interview with the Director of Nursing (DON) on 11/23/2022 at 7:53 p.m., DON stated needing to check, facility's policy for the antibiotic stewardship and verified, antibiotic stewardship was supposed to be done by the IPN. 2. A review of Resident 99 admission Record indicated the facility admitted the resident on 11/1/2022 with diagnoses including chronic respiratory failure with hypoxia (low oxygen level), Chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breath) and atrial fibrillation (irregular heartbeat).
A review of Resident 99's MDS dated [DATE], Resident 99 was alert and able to verbalize needs.
A review of Resident 99's Physician Order dated 11/15/2022, indicated resident had an order for Keflex oral capsule 500 milligram (mg), give 500 mg by mouth every six hours for infection for seven days.
During an interview on 11/20/2022 at 10:45 a.m., with Infection Preventionist (IP) stated that she was the one assigned for antibiotic stewardship program but wasn't able to do it since the start of 2022. IP stated that according to their policy, antibiotic stewardship program starts when the nurse obtains an order of any antibiotic from the doctor. IP stated that all antibiotics should be assessed as soon as possible to rule out unnecessary use of antibiotic that can lead to antibiotic resistance to the residents.
3. A review of Resident 105's admission Record indicated the facility admitted the resident on 10/28/2022, with diagnoses including osteomyelitis (infection of the bone), human immunodeficiency virus (HIV-causes AIDS and interferes with the body's ability to fight infections) disease and Kaposi's sarcoma (skin cancer).
A review of Resident 105's MDS, dated [DATE], indicated Resident 105 was alert and able to verbalize needs. MDS also indicated that the resident was getting an antibiotic via intravenously.
A review of Resident 105's Physician Order dated 11/7/2022 indicated an order of Cefepime (antibiotic) hydrochloride two gram/100 milliliter, use two grams intravenously every 12 hours for osteomyelitis until 12/19/2022.
A review of Resident 105's Physician Order dated 10/28/2022 indicated an order Cubicin (antibiotic) solution use 500 milligram (mg) intravenously every 24 hours for osteomyelitis until 12/19/2022.
During an interview on 11/20/2022 at 10:45 a.m., with IPN stated that she was the one assigned for antibiotic stewardship program but wasn't able to do it since the start of 2022. IP stated that according to their policy, antibiotic stewardship program starts when the nurse obtains an order of any antibiotic from the doctor. IP stated that all antibiotics should be assessed as soon as possible to rule out unnecessary use of antibiotic that can lead to antibiotic resistance to the residents.
4. A review of Resident 150's admission Record indicated resident was admitted to the facility 11/17/2022, with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), urinary tract infection (UTI-infection in the urinary system [kidneys, bladder, or urethra]) with Escherichia coli (E. coli-type of bacteria) and HTN.
A review of Resident 150's History and Physical, indicated resident has the capacity to understand and make decision.
A record review of Resident 150's Order Summary Report, dated 11/17/2022, indicated that Resident 150 had an order for a nitrofurantoin microcrystal (antibiotic /anti-bacterial medicine) 100 milligram (mg) by mouth with meals for urinary tract infection (UTI) for 10 administration doses.
A review of Resident 150's Medical Records, indicated missing documentation for the facility's antibiotic stewardship monitoring.
During a concurrent record review and interview with the IPN on 11/20/202 at 12:01 p.m., IPN stated and verified, not being able to do the antibiotic stewardship. IPN stated that antibiotic stewardship monitoring was supposed to be done when a resident gets an order to start an antibiotic. IPN also stated that she was supposed to collaborate with the team to monitor appropriate use of antibiotics to the resident.
During an interview with the DON on 11/23/2022 at 7:53 p.m., DON stated needing to check, facility's policy for the antibiotic stewardship and verified, antibiotic stewardship was supposed to be done by the IPN.
e. A review of Resident 157's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including left knee replacement (hip join is replaced by a prosthetic implant) surgery, hyperlipidemia (abnormally high levels of fats in the blood) and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing).
A review of Resident 157's MDS, dated [DATE], indicated Resident 157's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A record review of Resident 157's Order Summary Report, dated 11/15/2022, indicated that Resident 157 had an order to start Augmentin oral tablet 875-125 mg to give 1 tablet by mouth two times a day for sinusitis (infection of the sinus).
A review of Resident 157's Medical Records, indicated missing documentation for the facility's antibiotic stewardship monitoring.
During a concurrent record review and interview with the IPN on 11/20/202 at 12:01 p.m., IPN stated and verified, not being able to do the antibiotic stewardship. IPN stated that antibiotic stewardship monitoring was supposed to be done when a resident gets an order to start an antibiotic. IPN also stated that she was supposed to collaborate with the team to monitor appropriate use of antibiotics to the resident.
During an interview with the DON on 11/23/2022 at 7:53 p.m., DON stated needing to check, facility's policy for the antibiotic stewardship and verified, antibiotic stewardship was supposed to be done by the IPN.
A review of facility's policy and procedure (P&P), undated, titled, Antibiotic Stewardship Program indicated that it is the facility's policy to implement an antibiotic stewardship program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment related cost. It further stated that the Infection Preventionist (IP) with the assistance of ASP team as needed will:
i. Review infections and monitor antibiotic usage patterns on a regular basis and obtain and review antibiogram for institutional trends of resistance.
ii. Obtain and review antibiograms for institutional trends of resistance
iii. Monitor antibiotic resistance patterns and clostridium difficile infections
iv. Report on number of antibiotics prescribed and the number of residents treated each month
v. Include a separate report for the number of residents on antibiotics that did not meet criteria for active infection.
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 F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure a designated Infection Preventionist Nurse (IPN) to adequately assesses, develops, implements, monitors, and manages the facility's ...
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Based on interview and record review, the facility failed to ensure a designated Infection Preventionist Nurse (IPN) to adequately assesses, develops, implements, monitors, and manages the facility's Infection Prevention Control Program (IPCP) when facility started a Coronavirus (COVID-19, a virus that causes respiratory illness that can spread from person to person) outbreak (a sudden rise in the number of cases of a disease); implement and monitor facility's Antibiotic (medication that fight bacterial infection) Stewardship Program (ASP); and update a specialized training for facility staff with infection control practices per state and federal guidelines during a COVID-19 outbreak.
These deficient practices resulted in non-compliance with facility's infection control in which a total of 27 residents tested positive for COVID-19 within the span of 11 days and have the potential to spread COVID-19 to the other 21 residents, staff, and visitors.
Cross reference to F880 and F881
Findings:
A review of facility's COVID-19 outbreak (a sudden rise in the number of cases of a disease) line listing (a list of residents and staff confirmed positive with COVID-19), as of 11/23/2022, indicated two residents were confirmed positive starting 11/10/2022.
A review of facility's Infection Control In-services, dated 5/23/2022 and 6/24/2022, indicated IPN completed an in-service to the facility staff. No other documentation indicated an in-service was provided when the first residents were confirmed positive on 11/10/2022.
A review of IPN's certificate of training, titled, Centers for Disease Control and Prevention (CDC) Nursing Home Infection Preventionist Training Course, indicated IPN received 19.3 hours of training on 9/17/2020. IPN stated and verified no other training was completed on an annual basis since the last certification.
During a concurrent interview and record review with the IPN on 11/19/2022 at 9:18 a.m., IPN stated that she currently had a dual role as the IPN and as the Director of Staff Development (DSD) in the facility. IPN stated working as an IPN every Tuesday and Thursday while Monday, Wednesday and Fridays were the DSD role. IPN stated and validated that no other staff works as an IPN and added inability to perform IPN duties and responsibilities such as infection control in-services to all the staff when outbreak was started and implementing facility's ASP. IPN stated not doing the ASP for a long time. IPN further stated that it is important to have a full time IPN to fully take control and manage the infection control program in the facility.
During a concurrent record review of five out of five sampled residents (Resident 3, 99, 105, 150, and 157) for ASP and interview with the IPN on 11/20/202 at 12:01 p.m., IPN stated and verified, not being able to do the antibiotic stewardship. IPN stated that antibiotic stewardship monitoring was supposed to be done when a resident gets an order to start an antibiotic. IPN also stated that she was supposed to collaborate with the team to monitor appropriate use of antibiotics to the resident.
A review of facility's Job Description, titled, Infection Control Coordinator, undated, indicated that the primary purpose of the job position is to plan, organize, develop, coordinate, and direct facility's infection control program and its activities in accordant with current federal, state, and local standards, guidelines, and regulations that govern such programs.
A review of facility's P&P, titled, COVID-19 Facility Mitigation Management Plan, updated 1/14/2022, indicated that the facility has an Infection Preventionists (IP) providing at least 40 hours a week. P&P also indicated that the IPN will be responsible for the implementation of the facility's Infection Prevention and Control Program, Antibiotic Stewardship Program, as well as Infection Prevention Quality Control.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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 that influenza (or flu, is a contagious viral infection) and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that influenza (or flu, is a contagious viral infection) and pneumonia (lung infection) vaccinations were offered and documented for four of five sampled residents (Resident 25, 43, 105 and 207) upon admission and during the Influenza season.
This deficient practice placed residents at a higher risk of acquiring and transmitting influenza and pneumonia to other residents in the facility.
Findings:
A review of Resident 25's admission Record indicated the facility originally admitted the resident on 10/5/2022 and readmitted the resident on 11/16/2022. Resident 25's diagnoses included COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person), pneumonia and kidney transplant.
A review of Resident 25's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 11/21/2022, indicated Resident 25 was alert and able to verbalize needs.
During a concurrent interview and record review on 11/20/2022 at 4:15 p.m., with Assistant Director of Nursing (ADON), Resident 25's medical chart was reviewed. The ADON stated that the admission packet for Resident 25 including the pneumonia and influenza informed consents were not filled out. The ADON further stated there were no documentation in the chart to indicate the resident's immunization status.
A review of Resident 43's admission Record indicated the facility originally admitted the resident on 10/5/2022 and readmitted the resident on 11/16/2022, with diagnoses including hypertension, diabetes (diseases that result in too much sugar in the blood) and COVID-19.
A review of Resident 43's MDS dated [DATE], indicated the resident was alert and able to verbalize needs.
During a concurrent interview and record review on 11/20/2022 at 4:15 p.m., with the ADON, Resident 43's medical chart was reviewed. The ADON stated that the influenza and pneumonia informed consents and refusal form for Resident 43 were not filled out. The ADON further stated that there were no immunization records for the resident in the chart.
A review of Resident 105's admission Record indicated the facility admitted the resident on 10/28/2022, with diagnoses including osteomyelitis (infection of the bone), Human immunodeficiency virus (HIV-causes AIDS and interferes with the body's ability to fight infections) disease and Kaposi's sarcoma (skin cancer).
A review of Resident 105's MDS, dated [DATE], indicated Resident 105 was alert and able to verbalize needs.
During an interview on 11/18/2022 at 7:12 p.m., Resident 105 stated that he was not offered influenza and pneumonia vaccinations while he was in the facility.
During a concurrent interview and record review on 11/20/2022 at 4:15 p.m., with the ADON, Resident 105's medical chart was reviewed. The ADON stated that there were no immunization records for the resident in the chart.
A review of Resident 207's admission Record indicated the facility originally admitted the resident on 10/5/2022 and readmitted the resident on 11/16/2022, with diagnoses including sepsis (life threatening complication of infection), COVID-19 and diverticulitis (inflammation of the colon).
A review of Resident 207's MDS, dated [DATE], indicated Resident 207 was alert and able to verbalize needs.
During a concurrent interview and record review on 11/20/2022 at 4:15 p.m., with the ADON, Resident 207's medical chart was reviewed. The ADON stated that there was a consent for influenza and pneumonia vaccination signed by Resident 207 on 11/6/2022, however, The ADON confirmed that there were no documentations in the chart to indicate that the resident had received the influenza and pneumonia vaccinations.
During an interview on 11/20/2022 at 4:03 p.m., with Infection Preventionist (IPN), the IPN stated that she started offering the influenza vaccination in the beginning of October 2022. The IPN also stated that upon admission, the nurses screen residents for influenza and pneumonia vaccination and if the residents refuse vaccines, they (residents) will need to sign a refusal form. The IPN further stated that once resident signed the consent, she would administer the influenza and pneumonia vaccine.
A review of the facility's policy and procedure titled Pneumococcal vaccine with revised date of 8/2016, indicated all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.
A review of the facility's policy and procedure titled Influenza vaccine with revised date of 8/2016, indicated all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccination against influenza.
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 F0885
(Tag F0885)
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 notify residents, resident's representatives, and families of suspe...
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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 residents, resident's representatives, and families of suspected or confirmed COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) cases in the facility along with mitigating actions in a timely manner for three of 21 sampled residents, (Residents 206, 151 and 152).
This deficient practice resulted in a delay of notification of resident, resident representative and families regarding COVID-19 status in the facility.
Findings:
A. A review of Resident 206's admission Record indicated Resident 206 was originally admitted to the facility on [DATE] with diagnosis including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), anemia (a condition which the blood does not have enough health red blood cells) and hyperlipidemia (abnormally high levels of fats in the blood).
A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 11/21/2022, indicated Resident 206's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required limited from staff for activities of daily living (ADLs- bed mobility, transfer, toilet use and personal hygiene).
On 11/20/2022 at 7:21 p.m., during an interview with Resident 206, resident stated he was not aware of the COVID-19 outbreak or status of the facility and was not informed of any COVID-19 cases in the facility upon admission.
During an interview with Infection Preventionist (IPN), on 11/19/2022 at 9:43 a.m. the IPN indicated there were total of 17 residents who tested positive for COVID-19. The IPN stated the first COVID-19 positive resident with symptoms was tested on [DATE]. The IPN further stated, she was not aware if the Administrator notified residents, resident's representatives, and families of any suspected of confirmed COVID-19 cases in the facility. The IPN further stated, it should have been done upon any suspected or confirmed cases of COVID-19 in the facility.
During an interview with Administrator, on 11/19/2022 at 12:10 p.m., the Administrator stated he was unable to provide proof that the residents, resident representative, and families were notified of the COVID 19 outbreak on 11/10/2022.
B. A review of Resident 151's admission Record indicated the facility admitted Resident 151 on 11/17/2022 with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) with hypoxia (absence of enough oxygen in the tissue to sustain bodily functions) and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe).
A review of the MDS, dated [DATE], indicated Resident 151's cognitive skills for daily decision-making were intact and required limited to extensive assistance from staff for ADLs.
A review of Resident 151's chart, indicated no documentation that Resident 151 was made aware regarding any confirmed positive in the facility.
During an initial tour on 11/18/2022 at 6:46 p.m., Resident 151 stated that she was unaware that there were some residents in the facility with confirmed COVID-19 infection. Resident 151 stated that she was questioning the staff on the reason she couldn't come out of the room and added that she has been seeing the staff putting on gown on the other rooms next to hers.
C. A review of Resident 152's admission Record indicated the facility admitted Resident 152 on 11/3/2022 with diagnoses including left knee replacement (joint is replaced by a prosthetic implant [artificial device that replaces a missing body part]) surgery, difficulty in walking and hyperlipidemia (abnormally high levels of fats in the blood).
A review of the MDS, dated [DATE], indicated Resident 152's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs.
A review of Resident 152's chart, indicated no documentation that Resident 152 was made aware regarding any confirmed positive in the facility.
During an initial tour on 11/18/2022 at 7:05 p.m., Resident 152 stated that she was not aware that there was a confirmed COVID-19 positive in the facility and added that no one had explained to her the reason she needed to be in a yellow zone (isolation) room.
During a concurrent interview and record review with the IPN on 11/19/2022 at 9:43 a.m., IPN stated that notification for any COVID-19 confirmed cases should be done by the nursing supervisors and or the DON to all the residents, family and representatives as soon as possible once they were made aware of the result. The IPN further stated and verified not having any notification logs, letters, and or emails sent during the first confirmed positive resident on 11/10/2022.
A review of the facility's policy and procedures titled, COVID-19 Facility Mitigation Management Plan, updated 1/14/2022, indicated, facility will designate staff to inform residents, their representative and families of those residing in the facility by 5:00 p.m. the next calendar day following the occurrence of:
-Either a single confirmed infection of COIVD-19, or
-Three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other.
-Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered.
The same policy further indicated other appropriate ways of informing families and representatives as needed: via text alerts, website posting, paper notification and recorded phone messages.
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 interview and record review, the facility failed to ensure all healthcare personnel (HCP) had COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, caus...
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Based on interview and record review, the facility failed to ensure all healthcare personnel (HCP) had COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) testing as required during a COVID 19 outbreak.
This deficient practice placed other residents, staff, and visitors at risk for COVID-19.
Cross Reference F882
Findings:
During a review of the facility's census, dated 11/18/2022, the census indicated the facility had 48 in-house residents that included nine residents housed in the yellow zone and 16 residents housed in the red zone.
During a concurrent interview and record review with the Administrator (ADM), on 11/21/2022 at 11:30 a.m., the ADM COVID 19 test result dated 11/15/2022 was reviewed. The ADM's COVID 19 test result indicated the sample was not received. ADM stated he was not aware that his COVID 19 sample was not received.
During an interview on 11/21/2022 at 9:55 a.m. the Infection Preventionist Nurse (IPN) stated the facility was doing COVID 19 testing for all HCP starting on the week of 11/9/2022. The IPN stated she does not keep a log of who got tested and she had to check the COVID 19 test result on the website one by one. The IPN further stated she was not in front of the staff when swabbing for the COVID 19 test. The IPN further sated it would have been a better idea if someone was present during the swapping for monitoring purposes and logging it in to ensure everyone was counted for. The IPN further stated she can easily missed out on any HCP that did not test. IPN further stated that each employee can access their result and notify her for any issues such as positive result or sample not received. The IPN further stated that the staff can sign up via email and text messages for their result. The IPN stated that the risk of not getting everyone tested during a COVID 19 outbreak, could place other residents and staff at risk for COVID 19.
A review of the facility's policy and procedures titled COVID 19 Facility Mitigation Management Plan, with revised date of 1/14/2022, indicated, as soon as possible after on or (more) COVID 19 positive individuals (residents or Healthcare Personnel [HCP]) is identified in the facility, serial retesting of all residents and HCP who test negative upon the prior round of testing should be performed every three to seven days until no new cases identified among residents in two sequential rounds of testing over 14 days.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most California facilities.
- • 42% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 82 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Brentwood Health's CMS Rating?
CMS assigns BRENTWOOD HEALTH CARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Brentwood Health Staffed?
CMS rates BRENTWOOD HEALTH CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 42%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Brentwood Health?
State health inspectors documented 82 deficiencies at BRENTWOOD HEALTH CARE CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 81 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 Brentwood Health?
BRENTWOOD HEALTH CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by NAHS, a chain that manages multiple nursing homes. With 59 certified beds and approximately 56 residents (about 95% occupancy), it is a smaller facility located in SANTA MONICA, California.
How Does Brentwood Health Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, BRENTWOOD HEALTH CARE CENTER's overall rating (3 stars) is below the state average of 3.1, staff turnover (42%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Brentwood Health?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Brentwood Health Safe?
Based on CMS inspection data, BRENTWOOD HEALTH CARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-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 Brentwood Health Stick Around?
BRENTWOOD HEALTH CARE CENTER has a staff turnover rate of 42%, 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 Brentwood Health Ever Fined?
BRENTWOOD HEALTH CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Brentwood Health on Any Federal Watch List?
BRENTWOOD HEALTH CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.