MACLAY HEALTHCARE CENTER
For profit - Corporation
141 Beds
SERRANO GROUP
Data: November 2025
6 Immediate Jeopardy citations
Trust Grade
0/100
#1060 of 1155 in CA
Photo by Maclay Healthcare Center
Photo by Maclay Healthcare Center
Photo by Maclay Healthcare Center
1 / 5 photos
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Maclay Healthcare Center has received a Trust Grade of F, indicating poor performance with significant concerns about resident care. It ranks #1060 out of 1155 nursing homes in California, placing it in the bottom half of facilities statewide, and #318 out of 369 in Los Angeles County, meaning there are only a few better options locally. While the facility shows an improving trend, reducing issues from 67 in 2024 to 19 in 2025, it still has alarming problems, including $311,888 in fines, which is higher than 97% of California facilities, suggesting ongoing compliance issues. Staffing is average with a 3/5 rating, and the turnover rate is 41%, which is close to the state average. However, there were critical incidents, such as a resident being physically harmed during a fight and another being served food containing allergens, which could lead to severe health risks. Overall, while there are some signs of improvement, families should be cautious due to the facility's serious shortcomings.
- Trust Score
- F
- In California
- #1060/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 41% turnover. Near California's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $311,888 in fines. Higher than 81% of California facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 182 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 9%
Review needed
67 → 19 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 67 issues
2025: 19 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (41%)
7 points below California average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below California average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 41%
Near California avg (46%)
Typical for the industry
Federal Fines: $311,888
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: SERRANO GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 182 deficiencies on record
6 life-threatening 6 actual harm
Sept 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1). On 8/29/2025 at approximately 4:15 p.m., while Resident 1 and Resident 2 were both in Room A (Resident 1 and Resident 2's shared room), Resident 2, using his (Resident 2) three fingers (did not specify which hand), pushed Resident 1's back, between the shoulder blades (a large, triangular-shaped bone located on the back of the upper rib cage, one on each side of the body). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. As a result, Resident 1 fell on the floor in a semi-sitting position (a partially upright body position) leaning on his (Resident 1) right side.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/28/2025 with diagnoses including schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 2/20/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/27/2025, the MDS indicated Resident 1 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from the facility staff with toileting hygiene, showers, and lower body dressing. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching assistance) with toilet transfer, chair to bed transfers, and walking 150 feet (ft-unit of measurement). During a review of Resident 1's Care Plan, initiated on 8/29/2025, the Care Plan indicated Resident 1 was pushed by roommate (Resident 2) and landed on his (Resident 1) right side. The Care Plan indicated Resident 1 was at risk for physical injury, pain, and emotional distress. b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/12/2024 with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder, chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). During a review of Resident 2's H&P, dated 1/13/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive functioning was intact. The MDS indicated Resident 2 required moderate assistance from the facility staff with showers and lower body dressing. The MDS indicated Resident 2 was independent with ambulating 50 ft and required supervision with ambulating 150 ft. During a review of Resident 2's Care Plan (not titled), initiated on 8/27/2024, the Care Plan indicated Resident 2 had a history of behavioral and emotional challenges such as verbal disagreements with his (Resident 2) roommate (name not indicated). During a review of Resident 2's Care Plan (not titled), initiated on 8/29/2025, the Care Plan indicated Resident 2 was involved in a physical altercation (confrontation or argument that escalates to physical aggression, involving physical force or contact between individuals) with another resident (Resident 1), resulting in the resident (Resident 1) being pushed and found on the floor. During a review of Resident 2's change of condition (COC - when there is a sudden significant change in a resident's health status) form, dated 8/29/2025, the COC form indicated on 8/29/2025 (time not indicated), Resident 2 had an episode of physical altercation with another resident (Resident 1). The COC form indicated that Resident 2 admitted to pushing another resident (Resident 1) that resulted in the other resident (Resident 1) to be found sitting down on the floor on his (Resident 1) right side. c. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 1/18/2025 and readmitted on [DATE] with diagnoses including type 2 DM, muscle weakness, and personal history of other (healed) physical injury and trauma. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive functioning was intact. The MDS indicated Resident 3 was independent and was using a wheelchair. During an interview on 9/15/2025, at 10:40 a.m. with Resident 3, Resident 3 stated on the day of the incident between Resident 1 and Resident 2 (Resident 3 could not recall the exact date but stated it was during the afternoon), Resident 3 was resting in bed in Room B (Resident 3's room that is in front of Room A), when he (Resident 3) heard Resident 2 screamed saying that he (Resident 2) had told him (Resident 1) not to make a mess. Resident 3 stated he (Resident 3) could not recall if Resident 1 replied to Resident 2. Resident 3 stated that approximately two to three minutes after he (Resident 3) heard Resident 2's voice, he (Resident 3) heard a loud noise. Resident 3 stated he (Resident 3) immediately went outside (in a wheelchair) into the hallway in front of Room A and saw Resident 1 lying on the floor, on the side of Resident 1's bed facing the window. Resident 3 stated Resident 1's legs were visible on the floor from the hallway. Resident 3 stated Resident 2 was standing in the middle of the room. Resident 3 stated Resident 2 came out of the room and told Resident 3 that he (Resident 2) pushed Resident 1 to the floor and that he (Resident 2) was worried that he (Resident 2) would get in trouble. During an interview on 9/15/2025 at 11:09 a.m. with Resident 2, Resident 2 stated that on 8/29/2025, at approximately 4:15 p.m., he (Resident 2) pushed Resident 1's back with his three fingers (did not indicate which hand) and Resident 1 fell and sat on the floor. Resident 2 stated that Resident 1 had a bowel movement on his (Resident 1) bed and told Resident 2 that he (Resident 1) would defecate on Resident 2's bed as well. Resident 2 stated that Resident 1 was walking towards Resident 2's bed when he (Resident 2) approached and pushed Resident 1's back between his (Resident 1) shoulder blades. During a concurrent interview and record review on 9/15/2025 at 12:17 p.m. with the Acting Director of Nursing (DON), Resident COC form, initiated on 8/29/2025, at 16:20 p.m., was reviewed. The COC form indicated that on 8/29/2025 (time not indicated) Resident 1's roommate (Resident 2) pushed Resident 1 and Resident 1 fell on his (Resident 1) right side. The Acting DON stated that on 8/29/2025, at approximately 4:30 p.m., the Director of Staff Development asked her (Acting DON) to go to Room A. The Acting DON stated she (Acting DON) immediately went to Room A and saw Resident 1 on the floor next to Resident 1's bed. The Acting DON stated that Resident 2 admitted to pushing Resident 1 because he (Resident 2) was bothered by the smell of Resident 1's bowel movement. During an interview on 9/15/2025 at 1:47p.m. with the Acting DON, the Acting DON stated that the facility failed to keep Resident 1 free from physical abuse. The Acting DON stated the incident of physical altercation on 8/29/2025 between Resident 1 and Resident 2 was an incident of physical abuse and had the potential for Resident 1 to sustain fractures, contusion (an injury that occurs when tissue is damaged by a blunt force causing bleeding under the skin and discoloration), and negatively affect Resident 1's emotional well-being. During an interview on 9/15/2025 at 1:55 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 8/29/2025, at approximately 4: 10 p.m., Resident 2 approached him (LVN 1) and informed that Resident 1 had a bowel movement and needed assistance. LVN 1 stated that approximately two to three minutes after (approximately 4:15 p.m.) talking to Resident 2, he (LVN 1) went to Room A and found Resident 1 on the floor near the foot of Resident 1's bed, leaning towards his (Resident 1) right side, in a semi-sitting position. LVN 1 stated that he immediately got in between Resident 1 and Resident 2 since Resident 2 was standing too close to Resident 1. LVN 1 stated that Resident 2 said that he (Resident 2) pushed Resident 1. LVN 1 stated that the incident of Resident 2 pushing Resident 1 on 8/29/2025 was an incident of physical abuse and had the potential for Resident 1 to sustain injuries such as fractures, head injury, and bleeding. During an interview on 9/15/2025 at 2:26 p.m. with Registered Nurse (RN) 1, RN 1 stated that on 8/29/2025 she (RN 1) was informed by LVN 1 that Resident 2 pushed Resident 1. RN 1 stated that she (RN 1) could not recall the exact time of the incident but when she (RN 1) entered Room A, Resident 1 was on the floor next to Resident 1's bed, lying towards his (Resident 1) right hip. RN 1 stated Resident 2 told her (RN 1) that he (Resident 2) pushed Resident 1. RN 1 stated that the incident of Resident 2 pushing Resident 1 on 8/29/2025 was an incident of physical abuse and had the potential for Resident 1 to sustain injuries, such as fractures. During a record review of the facility-provided policy and procedure titled, Abuse Prevention and Reporting Policy, last reviewed on 4/2025, the policy and procedure indicated, It is the policy of this facility to maintain a zero tolerance for abuse . All residents have the right to be free from abuse and mistreatment. Purpose - Ensure residents are protected from all forms of abuse (physical .). Definitions - Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment causing physical harm, pain, or mental anguish.
Aug 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (the use ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability) for one of three sampled residents (Resident 1). On 8/23/2025 at around 6:30 a.m., Certified Nursing Assistant (CNA) 1 flipped off (describes the act of extending the middle finger as a rude and offensive gesture to express anger, contempt, or annoyance toward someone, particularly in a non-verbal way) using two middle fingers of both hands, yelled obscenities, and called a derogatory and racial insult at Resident 1. This deficient practice resulted in Resident 1 being subjected to verbal abuse by CNA 1 while under the care of the facility.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/27/2023 with diagnoses including type 2 diabetes (a group of diseases that result in too much sugar in the blood), polyneuropathy (nerve damage), hypertension (elevated blood pressure), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/3/2025, the MDS indicated Resident 1's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The MDS indicated Resident 1 required substantial to maximal assistance (helper does more than half the effort) with showering, toileting, and lower body dressing. During a record review of Resident 1's Care Plan, dated 8/27/2025, the Care Plan indicated Resident 1 had potentially a psychosocial (relating to the interrelation of social factors and individual thought and behavior) well-being problem due to a verbal incident with staff member (CNA 1). During a record review of Resident 1's Progress Notes, dated 8/28/2025, the Progress Notes indicated on 8/23/2025, at around 5 p.m., Resident 1 went to the Staff Developer (DSD) and the Administrator (ADMIN), and reported that on 8/23/2025, at around 6:30 a.m., CNA 1 called him (Resident 1) a derogatory and racial insult. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/15/2025 with diagnoses including history of falling, acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood, and hypertension (elevated blood pressure). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact. The MDS indicated Resident 2 required substantial to maximal assistance (helper does more than half the effort) with showering, toileting, and lower body dressing. During an interview with Resident 1 on 8/28/2025 at 10:10 a.m., Resident 1 stated on 8/23/2025, at around 6:30 a.m., Resident 1 pressed the call light because he (Resident 1) wanted to be changed. Resident 1 stated CNA 1 answered his (Resident 1) call light, and he (Resident 1) told CNA 1 he wanted a different CNA to change him (Resident 1). Resident 1 stated CNA 1 flipped off at him (Resident 1) using two middle fingers of both hands. Resident 1 stated CNA 1 called him (Resident 1) a derogatory and racial insult. Resident 1 stated CNA 1 continued to yell obscenities at him (Resident 1). Resident 1 stated he (Resident 1) called the RN Supervisor 1 (RN 1) from his (Resident 1) cell phone to come to his (Resident 1) room to help him (Resident 1). Resident 1 stated he (Resident 1) told RN 1 that CNA 1 was yelling obscenities at him (Resident 1). During an interview with Resident 2 on 8/28/2025 at 12:10 p.m., Resident 2 stated on 8/23/2025 at 6:30 a.m., his roommate (Resident 1) pressed the call light and CNA 1 came inside the room to answer the call light. Resident 2 stated he (Resident 2) heard Resident 1 told CNA 1 that Resident 1 wanted a different CNA to change Resident 1. Resident 2 stated he (Resident 2) heard CNA 1 yell out obscenities and a derogatory and racial insult at Resident 1. Resident 2 stated CNA 1 should have walked away and called the RN 1, instead of staying in the room and yelling out obscenities at Resident 1. During an interview with RN 1 on 8/28/2025 at 12:30 p.m., RN 1 stated on 8/23/2025 at 6:30 a.m., Resident 1 called her because he (Resident 1) did not want CNA 1 to change him. RN 1 stated Resident 1 reported to her (RN 1) that CNA 1 called him (Resident 1) a derogatory and racial insult. RN 1 stated she (RN 1) did not report this verbal abuse allegation to anyone because she (RN 1) did not think anything of it. RN 1 stated she (RN 1) realized this was verbal abuse and should have reported to the abuse coordinator within two hours. RN 1 stated she (RN 1) was very sorry for not reporting the verbal abuse right away. During an interview with the ADMIN and Director of Nurses (DON) on 8/28/2025 at 3:30 p.m., the ADMIN stated Resident 1 reported to her (ADMIN) and the DSD that on 8/23/2025 at 6:30 a.m., CNA 1 went to answer his (Resident 1) call light, and Resident 1 requested for a different CNA. The ADMIN stated Resident 1 reported that CNA 1 yelled a derogatory and racial insult at him (Resident 1). The ADMIN stated she (ADMIN) did not know Resident 1 had reported this to RN 1 on 8/23/2025. The ADMIN and DON stated the facility has no tolerance for any abuse and RN 1 should have reported this right away (facility reported to the State Survey Agency on 8/26/2025). The ADMIN stated that CNA 1 and RN 1 will be terminated effective immediately. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated 4/2021, the policy and procedure indicated Residents have the right to be free from abuse. This includes but is not limited to verbal abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 an allegation of verbal abuse (the use of oral, written or g...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability) within two hours to the State Survey Agency (SSA). On 8/23/2025 at around 6:30 a.m., Certified Nursing Assistant (CNA) 1 flipped off (describes the act of extending the middle finger as a rude and offensive gesture to express anger, contempt, or annoyance toward someone, particularly in a non-verbal way) using two middle fingers of both hands, yelled obscenities, and called a derogatory and racial insult at Resident 1. The facility reported the verbal abuse incident on 8/26/2025 to the SSA. This deficient practice resulted in a delay in the investigation and placed Resident 1 at risk for further verbal abuse.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/27/2023 with diagnoses including type 2 diabetes (a group of diseases that result in too much sugar in the blood), polyneuropathy (nerve damage), hypertension (elevated blood pressure), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/3/2025, the MDS indicated Resident 1's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The MDS indicated Resident 1 required substantial to maximal assistance (helper does more than half the effort) with showering, toileting, and lower body dressing. During a record review of Resident 1's Care Plan, dated 8/27/2025, the Care Plan indicated Resident 1 had potentially a psychosocial (relating to the interrelation of social factors and individual thought and behavior) well-being problem due to a verbal incident with staff member (CNA 1). During a record review of Resident 1's Progress Notes, dated 8/28/2025, the Progress Notes indicated on 8/23/2025, at around 5 p.m., Resident 1 went to the Staff Developer (DSD) and the Administrator (ADMIN), and reported that on 8/23/2025, at around 6:30 a.m., CNA 1 called him (Resident 1) a derogatory and racial insult. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/15/2025 with diagnoses including history of falling, acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood, and hypertension (elevated blood pressure). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact. The MDS indicated Resident 2 required substantial to maximal assistance (helper does more than half the effort) with showering, toileting, and lower body dressing. During an interview with Resident 1 on 8/28/2025 at 10:10 a.m., Resident 1 stated on 8/23/2025, at around 6:30 a.m., Resident 1 pressed the call light because he (Resident 1) wanted to be changed. Resident 1 stated CNA 1 answered his (Resident 1) call light, and he (Resident 1) told CNA 1 he wanted a different CNA to change him (Resident 1). Resident 1 stated CNA 1 flipped off at him (Resident 1) using two middle fingers of both hands. Resident 1 stated CNA 1 called him (Resident 1) a derogatory and racial insult. Resident 1 stated CNA 1 continued to yell obscenities at him (Resident 1). Resident 1 stated he (Resident 1) called the RN Supervisor 1 (RN 1) from his (Resident 1) cell phone to come to his (Resident 1) room to help him (Resident 1). Resident 1 stated he (Resident 1) told RN 1 that CNA 1 was yelling obscenities at him (Resident 1). During an interview with Resident 2 on 8/28/2025 at 12:10 p.m., Resident 2 stated on 8/23/2025 at 6:30 a.m., his roommate (Resident 1) pressed the call light and CNA 1 came inside the room to answer the call light. Resident 2 stated he (Resident 2) heard Resident 1 told CNA 1 that Resident 1 wanted a different CNA to change Resident 1. Resident 2 stated he (Resident 2) heard CNA 1 yell out obscenities and a derogatory and racial insult at Resident 1. Resident 2 stated CNA 1 should have walked away and called the RN 1, instead of staying in the room and yelling out obscenities at Resident 1. During an interview with RN 1 on 8/28/2025 at 12:30 p.m., RN 1 stated on 8/23/2025 at 6:30 a.m., Resident 1 called her because he (Resident 1) did not want CNA 1 to change him. RN 1 stated Resident 1 reported to her (RN 1) that CNA 1 called him (Resident 1) a derogatory and racial insult. RN 1 stated she (RN 1) did not report this verbal abuse allegation to anyone because she (RN 1) did not think anything of it. RN 1 stated she (RN 1) realized this was verbal abuse and should have reported to the abuse coordinator within two hours. RN 1 stated she (RN 1) was very sorry for not reporting the verbal abuse right away. During an interview with the ADMIN and Director of Nurses (DON) on 8/28/2025 at 3:30 p.m., the ADMIN stated Resident 1 reported to her (ADMIN) and the DSD that on 8/23/2025 at 6:30 a.m., CNA 1 went to answer his (Resident 1) call light, and Resident 1 requested for a different CNA. The ADMIN stated Resident 1 reported that CNA 1 yelled a derogatory and racial insult at him (Resident 1). The ADMIN stated she (ADMIN) did not know Resident 1 had reported this to RN 1 on 8/23/2025. The ADMIN and DON stated the facility has no tolerance for any abuse and RN 1 should have reported this right away (facility reported to the State Survey Agency on 8/26/2025). The ADMIN stated that CNA 1 and RN 1 will be terminated effective immediately. During a review of the facility-provided policy and procedure titled, Abuse Investigation and Reporting, revised on 7/2027, the policy and procedure indicated, All reports of resident abuse . shall be promptly reported to local, state and federal agencies (as defined by current regulations). Reporting 1. All alleged violations involving abuse . will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/\certification agency responsible for surveying/licensing the facility . 2. An alleged violation of abuse . will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse.
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its policies and procedures (P&P) affecting...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its policies and procedures (P&P) affecting two of five sampled residents (Resident 1 & Resident 2) by failing to: A. Notify Resident 1's doctor and responsible party on 6/30/2025 that Resident 1 encountered a change of condition with injury. B. Provide Resident 2 with the right to refuse room changes. These deficient practices denied the residents and their responsible parties' their rights, and to information needed to make decisions related to residents' care needs. Findings: A. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/7/2022 with the diagnoses including muscle weakness, dysphagia (having difficulty swallowing), and hemiplegia and hemiparesis following cerebral infarction (weakness or lack of movement to one side of the body after a brain injury) affecting the left side. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 1 had moderate impairments with decision making tasks and understanding of questions. During a concurrent interview and observation on 7/2/2025 at 2:44 p.m. with Resident 1, Resident 1 stated, I was injured here like two days ago. Resident 1 showed his left elbow noted with skin discoloration of dark purple and blue partially covered with a band-aid. Resident 1 stated the incident happened while staff were using a lift machine (a device used for transferring residents to and from bed to wheelchair) and Resident 1's elbow hit the metal parts of the machine. During a concurrent interview and observation on 7/2/2025 at 2:55 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 observed Resident 1's left elbow and stated it was a hematoma. LVN 1 stated, A hematoma is internal bleeding under the skin or pretty much a bruise on his left elbow covered with a band aid. During an interview on 7/9/2025 at 12:43 p.m. with LVN 2, LVN 2 stated on 6/30/2025, LVN 2 was informed by a Certified Nursing Assistant (unknown) to go to Resident 1 because Resident 1 was bleeding. LVN 2 stated she (LVN 2) went to Resident 1's room and saw discoloration on the resident's left elbow. LVN 2 stated she (LVN 2) did not inform the Registered Nurse on duty, Resident 1's doctor, or the responsible party of Resident 1's change of condition with injury. LVN 2 stated, I failed to start the change of condition timely, I failed to notify the Registered Nurse supervisor, the family/responsible party, and the doctor of the change of condition. B. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/27/2023 with diagnoses including type two diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), polyneuropathy (muscle weakness, pain, numbness due to damaged peripheral nerves), and depression (a serious mental health condition affecting how one feels, thinks, and acts, impacting day to day functions). The admission Record indicated Resident 2 was self-responsible for decision making tasks related to care. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was fully alert and able to understand and answer questions. During a review of Resident 2's Room and/or Roommate Change Authorization/Notification form, dated 6/13/2025 (no time listed) and again on 7/2/2025, the Room and/or Roommate Change Authorization/Notification form indicated Resident 2 gave Verbal Consent to move rooms. The record did not have Resident 2's signature of acknowledging and agreeing to the room change and the facility staff signature/identifier on who completed the form. During an interview on 7/2/2025 at 3:12 p.m. with Resident 2, Resident 2 stated he (Resident 2) was told he (Resident 2) needed to move rooms and he (Resident 2) had no choice. Resident 2 stated he (Resident 2) was moved to the current room just earlier in the day. Resident 2 stated, When they moved me, I felt bad being stuck in another room. I didn't sign any papers to agree to the move, they just moved me. During an interview on 7/2/2025 at 3:58 p.m. with Social Services Assistant (SSA) 1, SSA 1 stated Resident 2 was moved into different rooms on 6/13/2025 and earlier today, 7/2/2025. SSA 1 stated, The failure is that it is important to notify and document the notification of the room changes because it is their right to agree or disagree to the room changes. Ultimately, it is up the resident or responsible party to make that decision. During a review of the facility provided P&P titled, Changes in Resident Condition, dated 11/3/2023, the P&P indicated The resident, attending physician and legal representative or interested family member are notified when changes in condition or certain events occur. The guidelines include: A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: -An accident involving the resident which results in injury and has the potential for requiring physician intervention; During a review of the facility provided P&P titled, Resident Rights, with last revision date of 12/2021, the P&P indicated Employees shall treat all residents with kindness, respect, and dignity. The P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; e. self-determination; h. be supported by the facility in exercising his or her rights; i. exercise his or her rights without interference, coercion, discrimination or reprisal form the facility; j. be informed about his or her rights and responsibilities; o. be notified of his or her medical condition and of any changes in his or her condition; p. be informed of, and participate in, his or her care planning and treatment; ai. refuse a transfer from a distinct part within the institution.
Jun 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the attending physician (MD) for one of three sampled reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the attending physician (MD) for one of three sampled residents (Resident 1) when:
1. The Skilled Nursing Facility (SNF) 1, was unable to provide Speech Therapy (ST) on 5/15/2025 when MD ordered an ST and swallow evaluation (a test done by a Speech-Language Pathologist (SLP) to figure out why a person is having trouble swallowing).
2. Resident 1 continued to have difficulty swallowing and pocketing (the act of storing food inside the mouth without swallowing it) after the Change in Condition (COC) on 5/15/2025.
These deficient practices resulted in Resident 1 not receiving the ST evaluation resulting in Resident 1 having a COC on 5/24/2025 where Resident 1 was noted with inability to eat, coughing and pocketing requiring transfer to General Acute Care Hospital (GACH) 1.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2024 and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, often affecting one arm, leg, and sometimes the face) following cerebral infarction (a brain attack where part of the brain's blood supply is blocked or severely reduced) affecting the right dominant side, dysphagia (difficulty swallowing) oropharyngeal (anything related to the middle part of the throat), dementia (a progressive state of decline in mental abilities), and depression (a common mental health condition that causes persistent sadness, loss of interest in activities, and changes in how you think, feel, and act).
During a review of Resident 1's care plan created on 3/5/2025, the care plan for nutritional problem or potential nutritional problems indicated intervention to monitor, document, and report as needed any sign and or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, and to provide and serve supplements as ordered.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/1/2025, the MDS indicated Resident 1 was able to understand and be understood. The MDS indicated Resident 1 required substantial to maximum assistance (helper does more than half the effort) with toileting, showering, upper and lower body dressing and putting on and taking off footwear and required partial to moderate assistance (helper does less than half the effort) with oral hygiene, and personal hygiene.
During a review of Resident 1's care plan created on 4/19/2025, the care plan for swallowing problem related to holding food in mouth and cheeks with intervention to check mouth after meal for pocketing food and debris and report to nurse, monitor, document, and report as needed any sign or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts to swallow and refusing to eat.
During a review of Resident 1's Physician Order Summary Report, dated 4/20/2025, the Physician Order Summary Report indicated a physician's order for regular diet pureed texture, nectar thickened liquids consistency, large portion protein per meal.
During a review of Resident 1's COC Evaluation, dated 5/15/2025 at 10:20 p.m., the COC Evaluation indicated Resident 1pocketing food when eating. Family Member (FM) 1 indicated Resident 1 having difficulty swallowing his food, Resident 1 pockets the food in his mouth. The MD was notified on 5/15/2025 at 7 p.m. with orders for speech and swallow evaluation, calorie count for seven days.
During a review of Resident 1's Physician Order Summary Report, dated 5/15/2025, the Physician Order Summary Report indicated a physician's order for Speech and swallow evaluation in the morning.
During a review of Resident 1's care plan created on 5/16/2025, the care plan for difficulty swallowing indicated interventions of speech and swallow eval, calorie count for seven days and to call MD for changes in Resident 1's conditions.
During a review of Resident 1's Progress Notes dated 5/16/2025 at 2:17 p.m., the Progress Notes indicated continued monitoring for difficulty swallowing. Resident 1 is noted with some difficulty swallowing meals.
During a review of Resident 1's Progress Notes dated 5/17/2025 at 1:26 p.m., the Progress Notes indicated Resident 1 is on monitoring for difficulty swallowing and pocketing the food in his mouth, still noted.
During a review of Resident 1's Progress Notes dated 5/18/2025 at 1:23 p.m., the Progress Notes indicated Resident 1 is on monitoring for difficulty swallowing and pocketing the food in his mouth, still noted.
During a review of Resident 1's COC Evaluation dated 5/24/2025 at 10:09 a.m., the COC Evaluation indicated Resident 1 noted slowly declining in mobility, unable to feed to sit in Resident 1's wheelchair.
During a review of Resident 1's Progress Notes dated 5/24/2025 at 1:13 p.m., the Progress Notes indicated Resident 1 was transferred to GACH 1 at 12:14 p.m. due to fever, decline in Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily), and unable to eat, coughing and pocketing food.
During an interview on 6/3/2025 at 12p.m. with the Restorative Nursing Assistant (RNA) 1, RNA 1 stated on Saturday 5/24/2025 prior to Resident 1 being discharged to GACH 1, RNA 1 attempted to feed Resident 1 pureed eggs and oatmeal and Resident 1 began to choke on the food. RNA 1 stated she reported to the nurse not sure who the nurse was, but Resident 1 was discharged shortly after that.
During an interview on 6/3/2025 at 12:31 p.m. with the Director of Rehab (DOR), the DOR stated have not had an ST in the facility since the beginning of May. The DOR stated if a resident requires ST, we will downgrade their diet and then send out the resident to the hospital if needed. The DOR stated last day of ST in the building was 5/5/2025. The DOR stated Resident 1 did not get the ST eval as ordered because the facility did not have an ST at that time. The DOR stated informed the Director of Nursing (DON), if Resident 1 was pocketing food or having signs of choking needed to be sent out to hospital this was during a clinical meeting with all department heads not sure of the date.
During an interview on 6/3/2025 at 12:36 p.m. with the DOR, the DOR stated Resident 1 was ordered to have ST three times a week for four weeks but since the ST resigned Resident 1 was discharged from ST. The DOR stated Resident 1 did not meet his goals, Resident 1 was discharged from ST because we could not provide the ST services for Resident 1. The DOR stated is not sure if the MD was notified that Resident 1 was not able to get ST eval as ordered by MD the one to contact the MD would have been nursing.
During a concurrent interview and record review on 6/3/2025 at 1:22 p.m. of Resident 1's progress notes with the DON, the DON stated there was no notification to MD regarding not having an ST in the building. The DON stated based on timesheet the ST's last day was on 5/5/2025 and Resident 1 was ordered an ST eval on 5/15/2025. The DON stated knowing that Resident 1 needed to transfer out if there was no ST within seven days. The DON stated Resident was discharged to GACH 1 on 5/24/2025, nine days after ST eval order, the DON stated does not think Resident 1 had a lot of pocketing of food. The DON reviewed progress notes dated 5/16/2025 through 5/24/2025 the DON stated the progress notes indicates that Resident 1 was still pocketing food and had difficulty swallowing. The DON stated there is a potential for weight loss and potential for aspiration if Resident 1 is pocketing food. The DON stated not sure if nurses notified MD that Resident 1 was continuing to pocket food. The DON stated it is not documented and cannot say the MD was notified. The DON stated nurses should have notified MD and/or DON that Resident 1 was continuing to pocket food. The DON stated can be a risk for resident not to be transferred in a timely manner. The DON stated there was delay of care. The DON stated as a SNF we should be able to provide ST, can be potential we cannot provide the right services and treatment and delay in treatment.
During a review of the facility's Policy and Procedure (P&P) titled, Specialized Rehabilitative Services, last revised on 4/2025, the P&P indicated our facility will provide Rehabilitative Services to residents as indicated by the MDS.
2. Specialized Rehabilitative Services include the following:
b. Speech Pathology/Audiology;
3. Therapeutic Services are provided only upon the written order of the resident's Attending Physician.
During a review of the facility's P&P titled, Changes in Resident Condition, last revised on 4/2025, the P&P indicated the resident, attending physician and legal representative or interested family member are notified when changes in condition or certain events occur. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when t...
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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when the facility failed to follow the Registered Dietitian's (RD- a food and nutrition expert who helps people improve their health through food choices and dietary changes) recommendations.
This deficient practice had the potential for Resident 1 to have unplanned weight loss.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2024 and readmitted the resident on 3/19/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, often affecting one arm, leg, and sometimes the face) following cerebral infarction (a brain attack where part of the brain's blood supply is blocked or severely reduced) affecting the right dominant side, dysphagia (difficulty swallowing) oropharyngeal (anything related to the middle part of the throat), dementia (a progressive state of decline in mental abilities), and depression (a common mental health condition that causes persistent sadness, loss of interest in activities, and changes in how you think, feel, and act).
During a review of Resident 1's care plan created on 3/5/2025, the care plan for nutritional problem or potential nutritional problems indicated intervention to monitor, document, and report as needed any sign and or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, and to provide and serve supplements as ordered.
During a review of Resident 1's Weight Summary, the Weight Summary indicated the following Resident 1's weights:
- 4/4/2025 154 pounds (lbs.- unit of weight)
- 5/5/2025 151 lbs.
- 5/18/2025 148 lbs.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/1/2025, the MDS indicated Resident 1 was able to understand and be understood. The MDS indicated Resident 1 required substantial to maximum assistance (helper does more than half the effort) with toileting, showering, upper and lower body dressing and putting on and taking off footwear and required partial to moderate assistance (helper does less than half the effort) with oral hygiene, and personal hygiene.
During a review of Resident 1's Physician Order Summary Report, dated 4/20/2025, the Physician Order Summary Report indicated a physician's order for regular diet pureed texture, nectar thickened liquids consistency, large portion protein per meal.
During a review of Resident 1's Food and Nutrition Progress Notes dated 5/15/2025 at 5:13p.m. indicated weight loss related to variable oral intake, multiple medical conditions including dysphagia, dementia, and depression. The plan indicated to provide magic cup (a nutritional supplement designed to provide extra calories and protein for individuals who are experiencing involuntary weight loss or have difficulty consuming enough nutrients through regular meals) daily at lunch for one month.
During an interview on 6/3/2025 at 3:56 p.m. with the Director of Nursing (DON), the DON stated for RD recommendations the RD comes two times a week, reviews the weights then gives recommendations, the facility then has three days to follow up on the recommendations including weekends.
During a concurrent interview and record review on 6/3/2025 at 4:25 p.m. of Resident 1's Food and Nutrition Progress Notes with the DON, the DON stated could not find any recommendations for Resident 1. The DON stated the RD needs to put their recommendations into the Dietary Report. The DON stated Resident 1 was seen by RD on 5/15/2025. The DON reviewed Resident 1's Food and Nutrition Progress Notes and the DON stated RD recommended magic cup which was not provided to Resident 1. The DON stated there is a potential for the interventions not to be done and can lead to a further weight loss.
During a review of the facility's Policy and Procedure (P&P) titled, Weight Assessment and Intervention, last revised on 4/2025, the P&P indicated undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes:
b. the resident's calorie, protein, and other nutrient needs compared with the resident current intake. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss for example:
f. increased need for calories and or protein.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide Speech Therapy (ST) on 5/15/2025 when the Medical Doctor (MD) ordered an ST and swallow evaluation (a test done by a Speech-Languag...
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Based on interview and record review, the facility failed to provide Speech Therapy (ST) on 5/15/2025 when the Medical Doctor (MD) ordered an ST and swallow evaluation (a test done by a Speech-Language Pathologist (SLP) to figure out why a person is having trouble swallowing) for one of three sampled residents (Resident 1).
This deficient practice resulted in Resident 1 not receiving the ST eval resulting in Resident 1 having a COC on 5/24/2025 where Resident 1 was noted with inability to eat, coughing and pocketing requiring transfer to General Acute Care Hospital (GACH) 1.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2024 and readmitted the resident on 3/19/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, often affecting one arm, leg, and sometimes the face) following cerebral infarction (a brain attack where part of the brain's blood supply is blocked or severely reduced) affecting the right dominant side, dysphagia (difficulty swallowing) oropharyngeal (anything related to the middle part of the throat), dementia (a progressive state of decline in mental abilities), and depression (a common mental health condition that causes persistent sadness, loss of interest in activities, and changes in how you think, feel, and act).
During a review of Resident 1's care plan created on 3/5/2025, the care plan for nutritional problem or potential nutritional problems indicated interventions including to monitor, document, and report as needed any sign and or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, and to provide and serve supplements as ordered.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/1/2025, the MDS indicated Resident 1 was able to understand and be understood. The MDS indicated Resident 1 required substantial to maximum assistance (helper does more than half the effort) with toileting, showering, upper and lower body dressing and putting on and taking off footwear and required partial to moderate assistance (helper does less than half the effort) with oral hygiene, and personal hygiene.
During a review of Resident 1's care plan created on 4/19/2025, the care plan for swallowing problem related to holding food in mouth and cheeks with intervention to check mouth after meal for pocketing food and debris and report to nurse, monitor, document, and report as needed any sign or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts to swallow and refusing to eat.
During a review of Resident 1's Physician Order Summary Report, dated 4/20/2025, the Physician Order Summary Report indicated a physician's order for regular diet pureed texture, nectar thickened liquids consistency, large portion protein per meal.
During a review of Resident 1's COC Evaluation, dated 5/15/2025 at 10:20 p.m., the COC Evaluation indicated Resident 1pocketing food when eating. Family Member (FM) 1 indicated Resident 1 having difficulty swallowing his food. Resident 1 pockets the food in his mouth. The MD was notified on 5/15/2025 at 7 p.m. with orders for speech and swallow evaluation, calorie count for 7 days.
During a review of Resident 1's Physician Order Summary Report, dated 5/15/2025, the Physician Order Summary Report indicated a physician's order for Speech and swallow evaluation in the morning.
During a review of Resident 1's care plan created on 5/16/2025, the care plan for difficulty swallowing indicated interventions of speech and swallow evaluation, calorie count for 7 days and to call MD for changes in Resident 1's conditions.
During a review of Resident 1's Progress Notes dated 5/16/2025 at 2:17 p.m., the Progress Notes indicated continued monitoring for difficulty swallowing. Resident 1 is noted with some difficulty swallowing meals.
During a review of Resident 1's Progress Notes dated 5/17/2025 at 1:26 p.m., the Progress Notes indicated Resident 1 is on monitoring for difficulty swallowing and pocketing the food in his mouth, still noted.
During a review of Resident 1's Progress Notes dated 5/18/2025 at 1:23 p.m., the Progress Notes indicated Resident 1 is on monitoring for difficulty swallowing and pocketing the food in his mouth, still noted.
During a review of Resident 1's COC Evaluation dated 5/24/2025 at 10:09 a.m., the COC Evaluation indicated Resident 1 noted slowly declining in mobility, unable to feed to sit in Resident 1's wheelchair.
During a review of Resident 1's Progress Notes dated 5/24/2025 at 1:13 p.m., the Progress Notes indicated Resident 1 was transferred to GACH 1 at 12:14 p.m. due to fever, decline in Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily), and unable to eat, coughing and pocketing food.
During an interview on 6/3/2025 at 12p.m. with the Restorative Nursing Assistant (RNA) 1, RNA 1 stated on Saturday 5/24/2025 prior to Resident 1 being discharged to GACH 1, RNA 1 attempted to feed Resident 1 pureed eggs and oatmeal and Resident 1 began to choke on the food. RNA 1 stated she reported to the nurse not sure who the nurse was, but Resident 1 was discharged shortly after that.
During an interview on 6/3/2025 at 12:31 p.m. with the Director of Rehab (DOR), the DOR stated have not had an ST in the facility since the beginning of May. The DOR stated if a resident requires ST, we will downgrade their diet and then send out the resident to the hospital if needed. The DOR stated last day of ST in the building was 5/5/2025. The DOR stated Resident 1 did not get the ST evaluation as ordered because the facility did not have an ST at that time. The DOR stated informed the Director of Nursing (DON), if Resident 1 was pocketing food or having signs of choking needed to be sent out to hospital this was during a clinical meeting with all department heads not sure of the date.
During an interview on 6/3/2025 at 12:36 p.m. with the DOR, the DOR stated Resident 1 was ordered to have ST three times a week for four weeks but since the ST resigned Resident 1 was discharged from ST. The DOR stated Resident 1 did not meet his goals, Resident 1 was discharged from ST because we could not provide the ST services for Resident 1. The DOR stated is not sure if the MD was notified that Resident 1 was not able to get ST eval as ordered by MD. The DOR stated the one to contact the MD would have been nursing.
During a concurrent interview and record review on 6/3/2025 at 1:22 p.m. of Resident 1's progress notes with the DON, the DON stated there was no notification to MD regarding not having an ST in the building. The DON stated based on timesheet the ST last day was on 5/5/2025 and Resident 1 was ordered an ST eval on 5/15/2025. The DON stated knew that Resident 1 needed to transfer out if there was no ST within 7 days. The DON stated Resident was discharged to GACH 1 on 5/24/2025, 9 days after ST eval order. The DON stated does not think Resident 1 had a lot of pocketing of food. The DON reviewed progress notes dated 5/16/2025 through 5/24/2025 the DON stated the progress notes indicates that Resident 1 was still pocketing food and had difficulty swallowing. The DON stated there is a potential for weight loss and potential for aspiration if Resident 1 is pocketing food. The DON stated as a SNF we should be able to provide ST and with no ST there is a potential we cannot provide the right services and treatment and there can be a delay in treatment.
During a review of the facility's Policy and Procedure (P&P) titled, Specialized Rehabilitative Services, last revised on 4/2025, the P&P indicated our facility will provide Rehabilitative Services to residents as indicated by the MDS.
2. Specialized Rehabilitative Services include the following:
b. Speech Pathology/Audiology;
3. Therapeutic Services are provided only upon the written order of the resident's Attending Physician.
During a review of the facility's P&P titled, Changes in Resident Condition, last revised on 4/2025, the P&P indicated the resident, attending physician and legal representative or interested family member are notified when changes in condition or certain events occur. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) w...
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Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) when:
1. The facility failed to accurately document on Resident 1's medication administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for calorie count for seven days.
2. The facility failed to accurately document Resident 1's Calorie Count.
These deficient practices resulted in inaccurate documentation of Resident 1's records.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2024 and readmitted the resident on 3/19/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, often affecting one arm, leg, and sometimes the face) following cerebral infarction (a brain attack where part of the brain's blood supply is blocked or severely reduced) affecting the right dominant side, dysphagia (difficulty swallowing) oropharyngeal (anything related to the middle part of the throat), dementia (a progressive state of decline in mental abilities), and depression (a common mental health condition that causes persistent sadness, loss of interest in activities, and changes in how you think, feel, and act).
During a review of Resident 1's care plan created on 3/5/2025, the care plan for nutritional problem or potential nutritional problems indicated intervention to monitor, document, and report as needed any sign and or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, and to provide and serve supplements as ordered.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/1/2025, the MDS indicated Resident 1 was able to understand and be understood. The MDS indicated Resident 1 required substantial to maximum assistance (helper does more than half the effort) with toileting, showering, upper and lower body dressing and putting on and taking off footwear and required partial to moderate assistance (helper does less than half the effort) with oral hygiene, and personal hygiene.
During a review of Resident 1's Physician Order Summary Report, dated 5/15/2025, the Physician Order Summary Report indicated a physician's order for calorie count for seven (7) days.
During a review of Resident 1's MAR for 5/2025 for calorie count for seven days, there was no indication of it being signed off by staff.
During a review of Resident 1's Calorie Count, the Calorie Count indicated on:
- 5/21/2025 for lunch ate 0 percent (%-a way of expressing a number as a fraction of 100).
- 5/21/2025 for dinner ate 25%
- 5/22/2025 for dinner ate 50%
- 5/23/2025 for lunch at 50%
- 5/23/2025 for dinner was left blank.
During a review of Resident 1's Meal Intake for May 2025, the Meal Intake indicated on:
- 5/21/2025 for lunch ate 26 to 50%
- 5/21/2025 for dinner refused to eat.
- 5/22/2025 for dinner refused to eat.
- 5/23/2025 for lunch ate 76-100%
- 5/23/2025 for dinner at 76-100%
During a concurrent interview and record review of Resident 1's Meal Intake, Calorie Count and MAR with the Director of Nursing (DON), the DON reviewed the Meal Intake with the Calorie Count and the DON stated should match and is not accurate. The DON stated for 5/21 it indicates Resident 1 ate 26 to 50% but the Calorie Count is documented as 0% for lunch and for dinner on 5/21 it indicates Resident refused but the Calorie Count indicates 25%. The DON reviewed Resident 1's MAR for 5/2025, the DON stated the calorie count for the seven days was not documented. The DON stated the MAR should have been checked off and initialed by the license staff, it needs to be signed and checked off indicating staff have done the task. The DON stated cannot validate the task was done. The DON stated the Meal Intake and Calorie Count should match for accuracy of records. The DON stated there is a potential for not being able to provide the right interventions and inconsistency.
During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, last revised on 4/2025, the P&P indicated the following information is to be documented in the resident medical record:
c. treatments or services performed.
3. Documentation in the medical record will be objective, complete, and accurate.
Apr 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to ensure staff were not wearing gloves in the hallway after exiting the rooms of three of six sampled residents (Resident 1, Resident 2, and Resident 3).
This deficient practice had the potential to spread infections and illnesses among residents and staff.
Findings:
During a review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted the resident on 6/29/2020, with a diagnosis of hemiplegia (complete paralysis [loss of muscle function] on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (also known as a stroke, damage to the brain from interruption of its blood supply).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 1's thought process was intact and required substantial assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).
During a concurrent observation and interview, on 4/28/2025, at 8:49 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 came out from Resident 1's room wearing a glove while holding a plastic bag and entered the dirty linen room. CNA 2 stated she was wearing gloves while holding the plastic bag with dirty linens to throw the bag away in the dirty linen room and she should not wear gloves in the hallway to prevent the spread of infection.
During a review of Resident 2's Record of Admission, the Record of admission indicated the facility admitted the resident on 2/19/2025, with a diagnosis of acute respiratory failure with hypoxia (a life-threatening condition where the lungs fail to adequately exchange oxygen and carbon dioxide, resulting in a deficiency of oxygen in the blood).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's thought process was intact and required moderate assistance from staff to complete ADLs.
During a concurrent observation and interview, on 4/28/2025, at 8:53 a.m., with CNA 3, in the hallway, CNA 3 wore gloves while transporting Resident 2 in a shower chair. CNA 3 stated she was wearing gloves while transporting Resident 2 in a shower chair and she should not be due to infection control.
During a review of Resident 3's Record of Admission, the Record of admission indicated the facility admitted the resident on 11/30/2022 with a diagnosis of type two diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's thought process was intact and was dependent on facility staff to complete ADLs.
During a concurrent observation and interview, on 4/28/2025, at 9:04 a.m., with CNA 4, CNA 4 wore gloves while holding linens and entered the dirty linen room. CNA 4 stated she was wearing gloves while holding the dirty linens. CNA 4 stated she did not place the linens in a plastic bag and carried the dirty linens to the dirty linen room. CNA 4 stated that she should put the dirty linens in a plastic bag and throw it away in the dirty linen room. CNA 4 further stated that she should not wear gloves in the hallway to prevent the spread of infection.
During an interview, on 4/28/2025, at 9:26 a.m., with the Infection Preventionist (IP) Nurse, the IP Nurse stated staff should not wear gloves in the hallways and staff should remove their gloves inside the room and wash their hands after to prevent the spread of infection and protect other residents and staff.
During an interview, on 4/28/2025, at 10:30 a.m., with the Director of Nursing (DON), the DON stated staff should not wear gloves in the hallway to prevent the spread of infection.
During a review facility's policy and procedure(P&P) titled, Personal Protective Equipment - Gloves, last reviewed 4/2025, the P&P indicated gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed.
During a review facility's policy and procedure(P&P) titled, Laundry and Bedding, Soiled, last reviewed 4/2025, the P&P indicated Soiled laundry/bedding shall be handled, transported and processed according to best practices for in
Mar 2025
7 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident ' s right to be free from physic...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1.
This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. On 3/16/2025 at 8:29 a.m., Resident 1 sustained abrasions (when the surface layers of the skin have been broken) on bilateral (both) knees and left thumb laceration (a deep cut or tear in skin). Resident 1 was sent to General Acute Care Hospital 1 (GACH 1) on 3/16/2025 for further evaluation and wound treatment. Resident 1 ' s left thumb laceration, measuring three (3) centimeters (cm - unit of measurement) in length, 0.2 cm in width, with unknown depth, required eight stitches (fine, threadlike materials used to hold the edges of a wound together). Based on the Reasonable Person Concept (what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer because of the noncompliance), due to Resident 1 ' impaired cognition (mental action or process of acquiring knowledge and understanding) and medical condition, an individual subjected to physical abuse may have physical pain, psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself).
On 3/19/2025 at 4:12 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ – a situation in which the facility ' s non-compliance with one or more requirements of participations had caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator and the Director of Nursing (DON) for the facility ' s failure to ensure that Resident 1 was kept free from physical abuse, as evidenced by Resident 2 injuring (to hurt or cause physical harm to another person) Resident 1 with a knife in the facility ' s smoking patio.
On 3/22/2025 at 5:48 p.m., the Administrator provided an acceptable IJ removal plan (a plan that identifies all actions the facility will take to immediately address the non-compliance that has resulted to the IJ situation) for the facility ' s failure to keep Resident 1 free from physical abuse.
On 3/22/2025 at 8:15 p.m., while onsite and after verifying the facility ' s full implementation of the IJ Removal Plan through observation, interview, and record review and determined the IJ situation was no longer present. The IJ situation was removed while onsite, in the presence of the Administrator and the DON.
The acceptable IJ Removal Plan included the following summarized actions:
1. On 3/16/2025 at 8:31 a.m., Resident 1 approached Nursing Station 500 for assistance. Registered Nurse 1 (RN 1) noted that Resident 1 had a cut on his left thumb with bleeding. RN 1 immediately gave first aid (initial assistance and care given to a resident who has been injured) and called Licensed Vocational Nurse (LVN) 1 to attend to Resident 1. RN 1 asked Resident 1 how he (Resident 1) got the cut on his (Resident 1) left thumb and Resident 1 stated, The guy (referring to Resident 2) is waving his (Resident 2) knife and I tried to seize (take hold of) it (knife). RN 1 immediately went to the smoking patio to check and found Resident 2 about to go inside the facility with no visual (sight) of the knife.
2. On 3/16/2025 at 9 a.m., RN 1 initiated a change of condition (COC – when there is a sudden significant change in a resident ' s health status) on Resident 2. RN 1 did a body check on Resident 2 and noted an abrasion (a superficial injury where the outermost layer of skin is rubbed or torn off, often caused by contact with a rough surface) on Resident 2 ' s left hand and wrist. RN 1 gave first aid to Resident 2 who denied any pain. RN 1 called Resident 2 ' s primary medical doctor (MD) 1 on 3/16/2025 at approximately 9 a.m. who ordered to transfer Resident 2 to GACH 2 for further evaluation. Resident 2 was assigned a 1:1 sitter (refers to a facility staff dedicated to providing continuous, one-on-one observation and care to a single resident, often to ensure their safety and prevent potential harm) to monitor his (Resident 2) aggressive behavior (any behavior intended to harm or cause distress to another person, either physically or emotionally). Resident 2 was transferred to GACH 2 for further psychiatric evaluation (a comprehensive assessment of an individual ' s mental health status, conducted by a qualified mental health professional) and treatment on 3/16/2025 at 6:10 p.m.
3. On 3/16/2025 at approximately 9:15 a.m., RN 1 initiated body assessment on Resident 1 and noted abrasions on both of his (Resident 1) knees. RN 1 initiated the COC on Resident 1. RN 1 called the paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) who arrived on 3/16/2025 at around 9:20 p.m. and transferred Resident 1 to GACH 1. RN 1 called the local police.
4. On 3/16/2025 at 9:05 p.m., Resident 1 came back from GACH 1 with eight stitches of sutures on Resident 1 ' s left thumb cut. Resident 1 was monitored for 72 hours for any fall complications and symptoms of emotional distress related to the altercation with Resident 2. Social Services staff continued to do a wellness visit to Resident 1 from 3/16/2025 to 3/19/2025 for emotional support and feeling of safety. The Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) visited Resident 1 on 3/17/2025 at 4 p.m. A Psychologist (a mental health professional who specializes in understanding and treating mental, emotional, and behavioral disorders) visited Resident 1 on 3/19/2025.
5. On 3/16/2025 at 2:30 p.m., the Director of Nursing (DON) via telephone had provided a 1:1 education (refers to individualized, one-on-one education provided to a single individual by a staff member or professional) to RN 1 regarding facility policies for abuse prevention that included all type of abuse. On 3/21/2025 and 3/22/2025, the DON provided 1:1 education to RN 2, Certified Nursing Assistant (CNA) 1, and CNA 2 regarding resident safety, supervision, and abuse prevention and management. Licensed Vocational Nurse (LVN) 1, who is currently on vacation, will be educated prior to coming back on the floor.
6. On 3/17/2025 at 2 a.m., the facility readmitted Resident 2 from GACH 2. The facility provided 1:1 sitter to Resident 2 to monitor his aggressive behavior. Social Services staff continued doing wellness visit (an appointment to create or update a personalized prevention plan focusing on preventative care and health risk assessments) to Resident 2 starting on 3/17/2025 at 1:17 p.m. who verbalized he (Resident 2) is doing well in the facility. On 3/18/2025 at 2:30 p.m., The Psychiatrist had seen Resident 2. On 3/18/2025 at 12:44 p.m., four local police officers came to the facility and apprehended Resident 2.
7. On 3/17/2025, the Administrator posted signs of No Weapons Allowed in the facility. The signs are posted in the front entrance door, facility entrance, and employee lounge. Additional posts will be done in other areas of the facility.
8. On 3/17/2025 until 3/22/2025, the Director for Staff Development (DSD), the Administrator, DON, and Assistant Administrator provided all facility staff with an in-service (a planned, workplace-based training program designed to enhance staff competency, improve job performance, and keep staff up to date with current best practices and new techniques) for all types of Abuse.
9. The facility made the following efforts to locate the knife used by Resident 2 to injure Resident 1:
a. On 3/16/2025, RN 1 and LVN 1 attempted to search Resident 2, however, Resident 2 refused.
b. On 3/16/2025, RN 1 and LVN 1 searched the Smoking Patio but could not locate the knife.
c. On 3/16/2025, the Administrator asked the police officer to conduct body search on Resident 2, the police officer stated that he cannot conduct it at this time.
d. On 3/16/2025, LVN 2 conducted a search in Resident 2 ' s room, in the trash cans, all drawers, closets, inside the shoes, under the mattresses, and the bathroom. Resident 2 ' s knife was not located.
e. On 3/16/2025, the housekeeper and laundry employees searched all trash carts, and laundry area, knife was not located.
f. On 3/19/2025, the Department heads conducted searches in all residents' rooms and belongings. Resident 2 ' s knife was not located.
g. On 3/19/2025, the Maintenance Supervisor searched the roof top, knife was not located.
h. On 3/22/2025, Administrator started reviewing the video footage to find the location of the knife. The Administrator is new, who started on 12/7/2024, was not given yet the capability to review the surveillance camera but is now able to review as of 3/22/2025. The Administrator is currently working with the Information Technology (IT) staff to assist if there will be any issues regarding the video surveillance footages.
i. The Administrator/designee will coordinate all efforts to exhaustively and continuously search for the missing knife used by Resident 2 until it (the knife) is found. Once knife is found the administrator will take a picture of where the knife was found, will place it in a bag, will handle with caution, and will turn it in to the police department. A notification will be sent to the SSA.
10. On 3/19/2025 to 3/22/2025, the DSD, Administrator, DON, and Assistant Administrator conducted in-services to staff regarding resident-to-resident verbal altercation and separating the residents to avoid escalation (an increase in the intensity or seriousness of something), recognizing potential threats, and handling situations where a weapon may be involved.
11. On 3/21/2025, a new policy and procedure for Firearms and Other Weapons was initiated and will be presented to the Medical Director on 3/24/2025 during an emergency meeting.
12. On 3/22/2025, RN Mentor in-serviced the Administrator and DON on the policy and procedure for abuse, how to detect and what is the definition of Abuse.
13. Department head managers during their routine rounds will conduct a safety room check on their assigned rooms to inspect the presence of sharp objects. Any kinds of sharp objects will be seized and reported to the Administrator for further follow-up.
14. Upon admission and during quarterly Interdisciplinary Team (IDT – a collaborative group of individuals from different discipline who work together to achieve a common goal) meetings, the Social Services will educate residents and their representatives about the policy and procedure on abuse and the facility ' s protocol of not bringing any sharp objects or weapons to the facility. Anyfindings of such will be confiscated immediately and will be handed to the Administrator/DON.
15. Upon returning from out on pass (refers to a planned, temporary absence of a resident from the facility, authorized by a physician ' s order, for a specific purpose, with the expectation of the resident ' s return), if residents or representatives bring any items back to the facility, the charge nurse or RN supervisor will be asking for any items the resident would like to be added to the inventory list.
(Cross Reference to F689)
Findings:
1. During a review of Resident 1 ' s admission Record (undated), the admission Record indicated the facility originally admitted Resident 1 on 9/15/2020 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thoughts), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 12/19/2024, the MDS indicated Resident 1 ' s cognition was moderately impaired. The MDS indicated Resident 1 ' s mobility (movement) device includes the use of a manual wheelchair (a wheeled mobility chair propelled by human power, either by the user themselves or by a caregiver pushing the wheelchair). The MDS indicated Resident 1 needing partial/moderate assistance (helper does less than half the effort and helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for shower or bathing self. The MDS indicated Resident 1 needing setup or clean-up assistance (helper sets up or cleans up; resident completes activity with helper assisting only prior to or following the activity) with eating.
During a review of Resident 1 ' s COC, dated 3/16/2025 at 9 a.m., the COC indicated Resident 1 came to the nursing station on 3/16/2025 at approximately around 8:40 a.m. with bleeding on left thumb. The COC indicated RN 1 conducted a body assessment on Resident 1 with noted laceration on left thumb and abrasion to bilateral knees. The COC indicated the paramedics transferred Resident 1 to GACH 1 for further evaluation.
2. During a review of Resident 2 ' s admission Record (undated), the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), schizophrenia, and hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (loss of blood flow to a part of the brain) affecting right dominant side.
During a review of Resident 2 ' s Inventory of Personal Effects (an itemized list of belongings of a resident), dated 7/19/2024, the Inventory of Personal effects did not indicate that Resident 2 was in possession of a knife. The form was completed and documented by CNA 4 and counter signed (a signature attesting the authenticity of a document already signed by another) by Resident 2.
During a review of Resident 2 ' s H&P, dated 7/22/2024, the H&P indicated Resident 2 had the mental capacity to understand and make decisions.
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognition was intact. The MDS indicated Resident 2 ' s mobility devices included the use of a walker (a mobility aid designed to assist individuals with difficulty walking) and manual wheelchair. The MDS indicated Resident 2 needed partial/moderate assistance with toilet transfer.
During a review of Resident 2's COC Evaluation, dated 3/17/2025, the COC indicated that on the morning of 3/16/2025 Resident 2 had an altercation with another resident (Resident 1).
During a concurrent observation and interview on 3/18/2025 at 10:10 a.m., with Resident 1 in Resident 1 ' s room, Resident 1 ' s left thumb was observed covered in a foam dressing. Resident 1 stated Resident 2 was disrespectful and used inappropriate words. Resident 1 stated, He (referring to Resident 2) has no respect for anybody, he (Resident 2) can ' t talk like that.
During an interview on 3/18/2025 at 10:34 a.m. with RN 1, RN 1 stated on 3/16/2025 at approximately 8:40 a.m. Resident 1 came to the nursing station and informed RN 1 that Resident 2 cut his (Resident 1) hand while Resident 1 was trying to take a knife from Resident 2 in the smoking patio. RN 1 also stated that Resident 1 was bleeding from the laceration on his left thumb. RN 1 stated while in the smoking patio, he (RN 1) questioned Resident 2 regarding possession of a knife but Resident 2 denied. RN 1 stated he (RN 1) did not inspect Resident 2 for the possession of a knife since Resident 2 denied having a knife. RN 1 stated it was him (RN 1) who opened the door to the smoking patio for a resident (name not specified) and left it open allowing Resident 1 and Resident 2 to enter the smoking patio without staff supervision. RN 1 stated that he (RN 1) was in the nursing station when Resident 1 and Resident 2 had a physical altercation.
During an interview on 3/18/2025 at 11:56 a.m. with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 on 3/16/2025. CNA 1 stated she was with another resident (name not specified) when the physical altercation between Resident 1 and Resident 2 happened in the smoking patio. CNA 1 stated the next time she (CNA 1) saw Resident 1 was in the hallway near the nursing station with RN 1 applying pressure on Resident 1 ' s bleeding hand. CNA 1 stated she (CNA 1) heard Resident 1 saying he (Resident 1) was trying to get a knife from another resident (Resident 2).
During an interview on 3/19/2025 at 9:15 a.m., with RN 1, RN 1 stated on 3/16/2025 between 8 a.m. and 8:30 a.m., Resident 1 and Resident 2 were smoking in the smoking patio without staff supervision. RN 1 stated Residents 1 and 2 should have been supervised while smoking in the patio. RN 1 stated the physical abuse incident could have been prevented if a staff member was supervising the two residents (Resident 1 and Resident 2).
During a concurrent observation, interview, and record review on 3/19/2025 at 12:10 p.m., the facility ' s video surveillance footage of the smoking patio with the recording date and time of 3/16/2025 at 8:22:57 a.m. (adjusted to reflect actual time) was observed and reviewed with the Administrator. The Administrator verified Resident 1 and Resident 2 as the residents in the video surveillance. Both residents (Resident 1 and Resident 2) were on their wheelchairs and were in the East Smoking Patio. The Administrator stated the video surveillance time stamp was not updated to reflect spring daylight savings time (refers to the practice of advancing clocks forward one hour from standard time, typically on the second Sunday in March, to make better use of natural daylight during the warmer months) and was one hour behind the actual time. The Administrator also stated the entrance to the East Smoking Patio was not visible in the video surveillance due to the location of the camera. The Administrator stated there was only one camera in the East Smoking Patio. The Administrator stated the following with time stamps adjusted to reflect the actual times:
a. On 3/16/2025 at 8:22:59 a.m., Resident 1 entered the East Smoking Patio from the hallway between Nursing Station 500 and the kitchen.
b. On 3/16/2025 at 8:24:08 a.m., Resident 2 entered the East Smoking Patio from the same entrance.
c. On 3/16/2025 at 8:26:58 a.m., Resident 1 stood up from his wheelchair and walked towards Resident 2 and started exchanging words.
d. On 3/16/2025 at 8:27:08 a.m., Resident 2 attempted to slap Resident 1 ' s hand while Resident 1 was pointing his hand towards Resident 2.
e. On 3/16/2025 at 8:29:22 a.m., Resident 2 pointed a knife towards Resident 1 ' s face.
f. On 3/16/2025 at 8:29:56 a.m., Resident 1 fell on the ground after trying to take the knife from Resident 2 ' s hands.
g. On 3/16/2025 at 8:30:20 a.m., Resident 1 went back and sat in his wheelchair and entered the facility at 8:30:42 a.m. The Administrator stated there was no facility staff present in the smoking patio as observed in the video surveillance.
During an interview on 3/19/2025 at 1:36 p.m., with the DON, the DON stated the facility failed to provide supervision to Resident 1 and Resident 2 on 3/16/2025 in the smoking patio, which led to a physical altercation between the two residents (Resident 1 and Resident 2) and Resident 1 sustaining an injury. The DON stated the facility has not found the knife used by Resident 2. The DON stated there is a possibility that the knife is still in the facility or in the possession of another resident.
During an interview on 3/19/2025 at 3:16 p.m. with the Administrator, the Administrator stated Resident 1 had informed the Administrator that Resident 2 was using inappropriate words towards Resident 1. The Administrator also stated the physical altercation between Resident 1 and Resident 2 could have been prevented if the two residents (Resident 1 and Resident 2) were supervised in the smoking patio and were immediately separated by staff once the verbal altercation started between Resident 1 and Resident 2. The Administrator stated there was physical abuse and that Resident 2 willfully acted on injuring Resident 1.
During an interview on 3/20/2025 at 2:45 p.m. with the Administrator, the Administrator stated the knife used by Resident 2 to injure Resident 1 was not found. The Administrator also stated body inspection was not done on Resident 2 since Resident 2 refused. The Administrator stated there was a possibility Resident 2 ' s knife is still in the facility.
During a review of the current facility-provided policy and procedure titled, Abuse, Neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress), Exploitation (means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion) and Misappropriation (the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident ' s belongings or money without the resident ' s consent) Prevention Program, revised on 4/2021 and reviewed on 4/2024, the policy and procedure indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: . b. other residents 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents
During a review of the current facility-provided policy and procedure titled, Smoking Policy-Residents, reviewed on 4/2024, the policy and procedure indicated, This facility has established and maintains safe resident smoking practices Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.
During a review of the current facility-provided policy and procedure titled, Abuse Policy, last reviewed on 4/2024, the policy and procedure indicated, Communities does not condone (accept and allow) resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including . other residents Residents have the right to be free from abuse 1. Providing a safe environment for the resident is one of the most basic and essential duties of our facility 4. Identification of abuse shall be the responsibility of every employee Resident abuse is defined as the willful infliction of injury, unreasonable . resulting in physical harm or pain, mental anguish Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking . and willful neglect of the resident ' s basic needs If abuse happens: 1. Separate the assailant from the victim. 2. Isolate the assailant to protect others.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision (refers to the ongoing monitoring...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of residents) for two of four residents (Resident 1 and Resident 2) when on 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1.
This deficient practice resulted in Resident 1 sustaining abrasions (when the surface layers of the skin have been broken) on bilateral (both) knees and left thumb laceration (a deep cut or tear in skin) on 3/16/2025 at 8:29 a.m. On 3/16/2025, Resident 1 was sent to General Acute Care Hospital 1 (GACH 1) for further evaluation and wound treatment. Resident 1 ' s left thumb laceration, measuring three (3) centimeters (cm - unit of measurement) in length, 0.2 cm in width, with unknown depth, required eight stitches (fine, threadlike materials used to hold the edges of a wound together, promoting healing).
On 3/19/2025 at 4:12 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator and the Director of Nursing (DON) for the facility ' s failure to provide staff supervision on 3/16/2025 at 8:26 a.m., when Resident 1 and Resident 2 were both in the facility ' s smoking patio.
On 3/22/2025 at 7:41 p.m., the DON provided an acceptable IJ removal plan (a plan that identifies all actions the facility will take to immediately address the non-compliance that has resulted to the IJ situation) for the facility ' s failure to provide supervision on 3/16/2025 at 8:26 a.m., to Resident 1 and Resident 2.
On 3/22/2025 at 8:15 p.m., while onsite and after verifying the facility ' s full implementation of the IJ Removal Plan through observation, interview, and record review, the SSA removed the IJ situation in the presence of the Administrator and the DON.
The acceptable IJ Removal Plan included the following summarized actions:
1. On 3/16/2025 at 8:31 a.m., Resident 1 approached Nursing Station 500 for assistance. Registered Nurse (RN) 1 noted that Resident 1 had a cut on his left thumb with bleeding. RN 1 immediately gave first aid (initial assistance and care given to a resident who has been injured) and called Licensed Vocational Nurse (LVN) 1 to attend to Resident 1. RN 1 asked Resident 1 how he (Resident 1) got the cut on his (Resident 1) left thumb and Resident 1 stated, The guy (referring to Resident 2) is waving his (Resident 2) knife and I tried to seize (take hold of) it (knife). RN 1 immediately went to the smoking patio to check and found Resident 2 about to go inside the facility with no visual (sight) of the alleged knife.
2. On 3/16/2025 at 9 a.m., RN 1 initiated a change of condition (COC - when there is a sudden significant change in a resident ' s health status) on Resident 2. RN 1 did a body check on Resident 2 and noted an abrasion (a superficial injury where the outermost layer of skin is rubbed or torn off, often caused by contact with a rough surface) on Resident 2 ' s left hand and wrist. RN 1 gave first aid to Resident 2 who denied any pain. RN 1 called Resident 2 ' s primary medical doctor (MD) 1 on 3/16/2025 at approximately 9 a.m. who ordered to transfer Resident 2 to GACH 2 for further evaluation. Resident 2 was assigned a 1:1 sitter (refers to a facility staff dedicated to providing continuous, one-on-one observation and care to a single resident, often to ensure their safety and prevent potential harm) to monitor his (Resident 2) aggressive behavior (any behavior intended to harm or cause distress to another person, either physically or emotionally). Resident 2 was transferred to GACH 2 for further psychiatric evaluation (a comprehensive assessment of an individual ' s mental health status, conducted by a qualified mental health professional) and treatment on 3/16/2025 at 6:10 p.m.
3. On 3/16/2025 at approximately 9:15 a.m., RN 1 initiated body assessment on Resident 1 and noted abrasions on both of his (Resident 1) knees. RN 1 initiated the COC on Resident 1. RN 1 called the paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) who arrived on 3/16/2025 at around 9:20 p.m. and transferred Resident 1 to GACH 1. RN 1 called the local police.
4. On 3/16/2025 at 9:05 p.m., Resident 1 came back from GACH 1 with eight stitches of sutures on Resident 1 ' s left thumb cut. Resident 1 was monitored for 72 hours for any fall complications and symptoms of emotional distress related to the altercation with Resident 2. Social Services staff continued to do a wellness visit to Resident 1 from 3/16/2025 to 3/19/2025 for emotional support and feeling of safety. The Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) visited Resident 1 on 3/17/2025 at 4 p.m. A Psychologist (a mental health professional who specializes in understanding and treating mental, emotional, and behavioral disorders) visited Resident 1 on 3/19/2025.
5. On 3/16/2025 at 2:30 p.m., the Director of Nursing (DON) via telephone had provided a 1:1 education (refers to individualized, one-on-one education provided to a single individual by a staff member or professional) to RN 1 regarding facility policies for abuse prevention that included all type of abuse and educating on the facility ' s policy and procedure on resident supervision specifically on following the residents ' smoking schedule to ensure that supervision is provided to residents in the smoking patio and on the other areas of the facility like the front entrance backyard and other patio location to ensure each resident ' s safety. On 3/21/2025 and 3/22/2025, the DON provided 1:1 education to RN 2, Certified Nursing Assistant (CNA) 1, and CNA 2 regarding resident safety, supervision, and abuse prevention and management. Licensed Vocational Nurse (LVN) 1, who is currently on vacation, will be educated prior to coming back on the floor.
6. On 3/17/2025 at 2 a.m., the facility readmitted Resident 2 from GACH 2. The facility provided 1:1 sitter to Resident 2 to monitor his aggressive behavior. Social Services staff continued doing wellness visit (an appointment to create or update a personalized prevention plan focusing on preventative care and health risk assessments) to Resident 2 starting on 3/17/2025 at 1:17 p.m. who verbalized he (Resident 2) is doing well in the facility. On 3/18/2025 at 2:30 p.m., The Psychiatrist had seen Resident 2. On 3/18/2025 at 12:44 p.m., four local police officers came to the facility and apprehended Resident 2.
7. On 3/17/2025, the Administrator posted signs of No Weapons Allowed in the facility. The signs are posted in the front entrance door, facility entrance, and employee lounge. Additional posts will be done in other areas of the facility.
8. On 3/17/2025 until 3/22/2025, the Director for Staff Development (DSD), the Administrator, DON, and Assistant Administrator provided all facility staff with an in-service (a planned, workplace-based training program designed to enhance staff competency, improve job performance, and keep staff up to date with current best practices and new techniques) for all types of Abuse.
9. The facility made the following efforts to locate the knife used by Resident 2 to injure Resident 1:
a. On 3/16/2025, RN 1 and LVN 1 attempted to search Resident 2, however, Resident 2 refused.
b. On 3/16/2025, RN 1 and LVN 1 searched the Smoking Patio but could not locate the knife.
c. On 3/16/2025, the Administrator asked the police officer to conduct body search on Resident 2, the police officer stated that he cannot conduct it at this time.
d. On 3/16/2025, LVN 2 conducted a search in Resident 2 ' s room, in the trash cans, all drawers, closets, inside the shoes, under the mattresses, and the bathroom. Resident 2 ' s knife was not located.
e. On 3/16/2025, the housekeeper and laundry employees searched all trash carts, and laundry area, knife was not located.
f. On 3/19/2025, the Department heads conducted searches in all residents' rooms and belongings. Resident 2 ' s knife was not located.
g. On 3/19/2025, the Maintenance Supervisor searched the roof top, knife was not located.
h. On 3/22/2025, Administrator started reviewing the video footage to find the location of the knife. The Administrator is new, who started on 12/7/2024, was not given yet the capability to review the surveillance camera but is now able to review as of 3/22/2025. The Administrator is currently working with the Information Technology (IT) staff to assist if there will be any issues regarding the video surveillance footages.
i. The Administrator/designee will coordinate all efforts to exhaustively and continuously search for the missing knife used by Resident 2 until it (the knife) is found. Once knife is found the administrator will take a picture of where the knife was found, will place it in a bag, will handle with caution, and will turn it in to the police department. A notification will be sent to the SSA.
10. On 3/19/2025 and 3/20/2025, the Department Heads conducted resident safety check on their assigned rooms using the resident inventory of personal belongings log to identify presence of any weapons or sharp objects after obtaining consents from self-responsible and alert residents and from residents ' responsible parties for residents who are not self-responsible.
11. On 3/19/2025 and 3/20/2025, the MDS Nurse, DON, and Activity Staff smoking attendant conducted 1:1 smoking observation of residents smoking in the smoking patio. After the smoking observation of residents, the MDS Nurse conducted a Smoking Risks Evaluation to determine if a smoker requires supervision or is an independent smoker during smoking time. The MDS Nurse have identified eight residents who require supervision during smoking and ten residents who can independently smoke in the smoking patio. All the 18 residents have the potential to be affected by the deficient practice therefore the facility shall provide residents supervision both for supervised and independent smokers to ensure residents ' safety.
12. On 3/21/2025, a new policy and procedure for Firearms and Other Weapons was initiated and will be presented to the Medical Director on 3/24/2025 during an emergency meeting.
13. Department head managers during their routine rounds will conduct a safety room check on their assigned rooms to inspect the presence of sharp objects. Any kinds of sharp objects will be seized and reported to the Administrator for further follow-up.
Findings:
1. During a review of Resident 1 ' s admission Record (undated), the admission Record indicated the facility originally admitted Resident 1 on 9/15/2020 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thoughts), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 12/19/2024, the MDS indicated Resident 1 ' s cognition was moderately impaired. The MDS indicated Resident 1 ' s mobility (movement) device includes the use of a manual wheelchair (a wheeled mobility chair propelled by human power, either by the user themselves or by a caregiver pushing the wheelchair). The MDS indicated Resident 1 needing partial/moderate assistance (helper does less than half the effort and helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for shower or bathing self. The MDS indicated Resident 1 needing setup or clean-up assistance (helper sets up or cleans up; resident completes activity with helper assisting only prior to or following the activity) with eating.
During a review of Resident 1 ' s Non-Compliance for Smoking Policy warning, dated 1/11/2024, the Non-Compliance for Smoking Policy warning indicated Resident 1 was given a verbal warning after Resident 1 was found on the smoking patio during a non-smoking time turning an ashtray dispenser (a device or container designed to hold and dispense ashtrays) upside down to remove any cigarettes that had already been discarded and Resident 1 chewed on the cigarette butts.
During a review of Resident 1 ' s care plan on chronic (recurring) disruptive behavior (actions that interfere with the functioning of an individual or a group and cause disturbances to those around them, often involving aggression, defiance, or violation of social norms), revised on 9/28/2024, the care plan indicated Resident 1 had a history of physical abuse with another resident (name not indicated).
During a review of Resident 1 ' s care plan with the focus on the resident as a smoker and chews tobacco, revised on 10/3/2024, the care plan indicated Resident 1 was non-compliant (disobedient) with the smoking policy and was on the patio during non-smoking time, turning the ash tray dispenser upside down to remove cigarette butts to chew. The care plan indicated Resident 1 will not smoke without supervision.
During a review of Resident 1 ' s COC, dated 3/16/2025 at 9 a.m., the COC indicated Resident 1 came to the nursing station on 3/16/2025 at approximately around 8:40 a.m. with bleeding on left thumb. The COC indicated RN 1 conducted a body assessment on Resident 1 with noted laceration on left thumb and abrasion to bilateral knees. The COC indicated the paramedics transferred Resident 1 to GACH 1 for further evaluation.
2. During a review of Resident 2 ' s admission Record (undated), the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), schizophrenia, and hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (loss of blood flow to a part of the brain) affecting right dominant side.
During a review of Resident 2 ' s Inventory of Personal Effects (an itemized list of belongings of a resident), dated 7/19/2024, the Inventory of Personal effects did not indicate that Resident 2 was in possession of a knife. The form was completed and documented by CNA 4 and counter signed (a signature attesting the authenticity of a document already signed by another) by Resident 2.
During a review of Resident 2 ' s H&P, dated 7/22/2024, the H&P indicated Resident 2 had the mental capacity to understand and make decisions.
During a review of Resident 2 ' s care plan on resident as a supervised smoker (refers to an individual who, due to assessed needs or identified risks, requires direct supervision or assistance when smoking to ensure their safety and the safety of those around them), revised on 10/10/2024, the care plan indicated Resident 2 was non-compliant with the use of the smoking apron, schedule time, and was at risk for injury from unsafe smoking practices. The care plan indicated Resident 2 ' s risk to smoke without supervision will be minimized, and Resident 2 will be monitored for any unsafe smoking practices.
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognition was intact. The MDS indicated Resident 2 ' s mobility devices included the use of a walker (a mobility aid designed to assist individuals with difficulty walking) and manual wheelchair. The MDS indicated Resident 2 needed partial/moderate assistance with toilet transfer.
During a review of Resident 2's COC Evaluation, dated 3/17/2025, the COC indicated that on the morning of 3/16/2025 Resident 2 had an altercation with another resident (Resident 1).
During a review of the facility ' s Smoking Schedule, (undated), the Smoking Schedule indicated that on Saturdays and Sundays, residents are scheduled to smoke between 9 a.m. to 9:30 a.m., 11 a.m. to 11:30 a.m., 1 p.m. to 1:30 a.m., 3 p.m. to 3:30 p.m., and 7 p.m. to 7:30 p.m.
During a concurrent observation and interview on 3/18/2025 at 10:10 a.m. with Resident 1 in Resident 1 ' s room, Resident 1 ' s left thumb was observed covered in a foam dressing. Resident 1 stated Resident 2 was disrespectful and used inappropriate words. Resident 1 stated, He (referring to Resident 2) has no respect for anybody, he (Resident 2) can ' t talk like that.
During an interview on 3/18/2025 at 10:34 a.m. with RN 1, RN 1 stated on 3/16/2025 at approximately 8:40 a.m. Resident 1 came to the nursing station and informed RN 1 that Resident 2 cut his (Resident 1) hand while Resident 1 was trying to take a knife from Resident 2 in the smoking patio. RN 1 also stated that Resident 1 was bleeding from the laceration on his left thumb. RN 1 stated while in the smoking patio, he (RN 1) questioned Resident 2 regarding possession of a knife but Resident 2 denied. RN 1 stated he (RN 1) did not inspect Resident 2 for the possession of a knife since Resident 2 denied having a knife. RN 1 stated it was him (RN 1) who opened the door to the smoking patio for a resident (name not specified) and left it open allowing Resident 1 and Resident 2 to enter the smoking patio with no staff present to supervise the two residents (Resident 1 and Resident 2). RN 1 stated that he (RN 1) was in the nursing station when Resident 1 and Resident 2 had a physical altercation.
During an interview on 3/18/2025 at 11:56 a.m. with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 on 3/16/2025. CNA 1 stated she was with another resident (name not specified) when the physical altercation between Resident 1 and Resident 2 happened in the smoking patio. CNA 1 stated the next time she (CNA 1) saw Resident 1 was in the hallway near the nursing station with RN 1 applying pressure on Resident 1 ' s bleeding hand. CNA 1 stated she (CNA 1) heard Resident 1 saying he (Resident 1) was trying to get a knife from another resident (Resident 2).
During a concurrent observation and interview on 3/18/2025 at 3:18 p.m. with Activity Staff (AS) 1 in the hallway, AS 1 was sitting in the hallway, near the smoking patio with doors closed. Two residents (names not indicated) were observed smoking in the patio through the glass panel on the doors. AS 1 stated the residents smoking in the patio are independent smokers but require supervision since occasionally, they pick up cigarette butts from the floor and try to chew them. AS 1 also stated she should have supervised residents while staying outdoors in the smoking patio. AS 1 stated the entire smoking patio is not visible from behind the hallway doors and she is not able to see all the residents in the patio. AS 1 stated all residents smoking in the patio should be supervised to prevent resident injury.
During an interview on 3/19/2025 at 9:15 a.m., with RN 1, RN 1 stated on 3/16/2025 between 8 a.m. and 8:30 a.m., Resident 1 and Resident 2 were smoking in the smoking patio without supervision. RN 1 stated Residents 1 and 2 should have been supervised while smoking in the patio.
During a concurrent interview and record review on 3/19/2025 at 11:22 a.m. with the MDS Specialist, Resident 2 ' s Smoking Evaluation, dated 10/10/2024, was reviewed. The Smoking Evaluation indicated Resident 2 was noted with episode of non-compliance with the use of the smoking apron and required periodic supervision. The MDS Specialist stated Resident 2 was a supervised smoker. The MDS Specialist also stated residents should not be smoking outside of the scheduled smoking times and all residents should be supervised by the facility staff while smoking.
During a concurrent observation, interview, and record review on 3/19/2025 at 12:10 p.m., the facility ' s video surveillance footage of the smoking patio with the recording date and time of 3/16/2025 at 8:22:57 a.m. (adjusted to reflect actual time) was observed and reviewed with the Administrator. The Administrator verified Resident 1 and Resident 2 as the residents in the video surveillance. Both residents (Resident 1 and Resident 2) were on their wheelchairs, were in the East Smoking Patio. The Administrator stated the video surveillance time stamp was not updated to reflect spring daylight savings time (refers to the practice of advancing clocks forward one hour from standard time, typically on the second Sunday in March, to make better use of natural daylight during the warmer months) and was one hour behind the actual time. The Administrator also stated the entrance to the East Smoking Patio was not visible in the video surveillance due to the location of the camera. The Administrator stated there was only one camera in the East Smoking Patio. The Administrator stated the following with time stamps adjusted to reflect the actual times:
a. On 3/16/2025 at 8:22:59 a.m., Resident 1 entered the East Smoking Patio from the hallway between Nursing Station 500 and the kitchen.
b. On 3/16/2025 at 8:24:08 a.m., Resident 2 entered the East Smoking Patio from the same entrance.
c. On 3/16/2025 at 8:26:58 a.m., Resident 1 stood up from his wheelchair and walked towards Resident 2 and they were exchanging words.
d. On 3/16/2025 at 8:27:08 a.m., Resident 2 attempted to slap Resident 1 ' s hand while Resident 1 was pointing his hand towards Resident 2.
e. On 3/16/2025 at 8:29:22 a.m., Resident 2 pointed a knife towards Resident 1 ' s face.
f. On 3/16/2025 at 8:29:56 a.m., Resident 1 fell on the ground after trying to take the knife from Resident 2 ' s hands.
g. On 3/16/2025 at 8:30:20 a.m., Resident 1 went back and sat in his wheelchair and entered the facility at 8:30:42 a.m. The Administrator stated there was no facility staff present in the smoking patio as observed in the video surveillance.
During an interview on 3/19/2025 at 1:36 p.m. with the DON, the DON stated the facility failed to provide supervision to Resident 1 and Resident 2 on 3/16/2025 in the smoking patio, which led to a physical altercation between the two residents (Resident 1 and Resident 2) and Resident 1 sustaining an injury. The DON stated the facility has not found the knife used by Resident 2. The DON stated there is a possibility that the knife is still in the facility or in the possession of another resident.
During an interview on 3/19/2025 at 3:16 p.m. with the Administrator, the Administrator stated Resident 1 had informed the Administrator that Resident 2 was using inappropriate words towards Resident 1. The administrator also stated the physical altercation between Resident 1 and Resident 2 could have been prevented if the two residents (Resident 1 and Resident 2) were supervised in the smoking patio.
During an interview on 3/20/2025 at 2:45 p.m. with the Administrator, the Administrator stated the knife used by Resident 2 to injure Resident 1 was not found. The Administrator also stated body inspection was not done on Resident 2 since Resident 2 refused. The Administrator stated there was a possibility Resident 2 ' s knife is still in the facility.
During a review of the current facility-provided policy and procedure titled, Smoking Policy-Residents, last reviewed on 4/2024, the policy and procedure indicated, This facility has established and maintains safe resident smoking practices Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.
During a review of the current facility-provided policy and procedure titled, Safety and Supervision of Residents, last reviewed on 4/2024, the policy and procedure indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities Individualized, Resident-Centered Approach to Safety: 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision Systems Approach to Safety: . 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment of if there is a change in the resident ' s condition.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident to resident altercation was thoroughly investigat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident to resident altercation was thoroughly investigated for two of four sampled residents (Resident 1 and Resident 2). On 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1.
This failure had the potential to place the residents at risk for further abuse.
Findings:
During a review of Resident 1 ' s admission Record (undated), the admission Record indicated the facility originally admitted Resident 1 on 9/15/2020 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thoughts), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 12/19/2024, the MDS indicated Resident 1 ' s cognition was moderately impaired. The MDS indicated Resident 1 ' s mobility (movement) device includes the use of a manual wheelchair (a wheeled mobility chair propelled by human power, either by the user themselves or by a caregiver pushing the wheelchair). The MDS indicated Resident 1 needing partial/moderate assistance (helper does less than half the effort and helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for shower or bathing self. The MDS indicated Resident 1 needing setup or clean-up assistance (helper sets up or cleans up; resident completes activity with helper assisting only prior to or following the activity) with eating.
During a review of Resident 1 ' s care plan on chronic (recurring) disruptive behavior (actions that interfere with the functioning of an individual or a group and cause disturbances to those around them, often involving aggression, defiance, or violation of social norms), revised on 9/28/2024, the care plan indicated Resident 1 had a history of physical abuse with another resident (name not indicated).
During a review of Resident 1 ' s History and Physical (H&P), dated 3/12/2025, the H&P indicated Resident 1 had the mental capacity to understand and make decisions.
During a review of Resident 2 ' s admission Record (undated), the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), schizophrenia, and hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (loss of blood flow to a part of the brain) affecting right dominant side.
During a review of Resident 2 ' s H&P, dated 7/22/2024, the H&P indicated Resident 2 had the mental capacity to understand and make decisions.
During a review of Resident 2 ' s care plan, dated 3/16/2025, the care plan indicated Resident 2 was involved in an alleged altercation with another resident (Resident 1).
During an interview on 3/18/2025 at 12:28 p.m. with the Administrator, the Administrator stated Registered Nurse (RN) 1 notified the Administrator that on 3/16/2025 at approximately 8:40 a.m., Resident 2 allegedly injured Resident 1 with a knife. The Administrator stated that on 3/16/25 police officers arrived at the facility and had requested the video surveillance of Resident 1 and Resident 2 ' s physical altercation in the East Smoking Patio. The Administrator stated she was not able to provide immediately the video surveillance to the police officers on that day. The Administrator stated the police officers left the faciity on 3/16/2025 at approximately 11:30 a.m. The Administrator stated the video surveillance requested was provided to the police on 3/17/2025. The Administrator stated the police officers came back to the facility on 3/18/2025 and informed the Administrator that after reviewing the video surveillance provided they were arresting Resident 2.
During a concurrent observation, interview, and record review on 3/19/2025 at 12:10 p.m., the facility ' s video surveillance footage of the smoking patio with the recording date and time of 3/16/2025 at 8:22:57 a.m. (adjusted to reflect actual time) was observed and reviewed with the Administrator. The Administrator verified Resident 1 and Resident 2 as the residents in the video surveillance. Both residents (Resident 1 and Resident 2) were on their wheelchairs, were in the East Smoking Patio. The Administrator stated the video surveillance time stamp was not updated to reflect spring daylight savings time (refers to the practice of advancing clocks forward one hour from standard time, typically on the second Sunday in March, to make better use of natural daylight during the warmer months) and was one hour behind the actual time. The Administrator also stated the entrance to the East Smoking Patio was not visible in the video surveillance due to the location of the camera. The Administrator stated there was only one camera in the East Smoking Patio. The Administrator stated the following with time stamps adjusted to reflect the actual times:
a. On 3/16/2025 at 8:22:59 a.m., Resident 1 entered the East Smoking Patio from the hallway between Nursing Station 500 and the kitchen.
b. On 3/16/2025 at 8:24:08 a.m., Resident 2 entered the East Smoking Patio from the same entrance.
c. On 3/16/2025 at 8:26:58 a.m., Resident 1 stood up from his wheelchair and walked towards Resident 2 and they were exchanging words.
d. On 3/16/2025 at 8:27:08 a.m., Resident 2 attempted to slap Resident 1 ' s hand while Resident 1 was pointing his hand towards Resident 2.
e. On 3/16/2025 at 8:29:22 a.m., Resident 2 pointed a knife towards Resident 1 ' s face.
f. On 3/16/2025 at 8:29:56 a.m., Resident 1 fell on the ground after trying to take the knife from Resident 2 ' s hands.
g. On 3/16/2025 at 8:30:20 a.m., Resident 1 went back and sat in his wheelchair and entered the facility at 8:30:42 a.m. The Administrator stated there was no facility staff present in the smoking patio as observed in the video surveillance.
During an interview on 3/19/2025 at 3:16 p.m. with the Administrator, the Administrator stated she should have requested the surveillance videos on all cameras to see the residents ' (Resident 1 and Resident 2) location after the incident of Resident 1 ' s and Resident 2 ' s physical altercation. The Administrator stated her investigation was not thorough.
During an interview on 3/21/2025 at 6:04 p.m. with the Administrator, the Administrator stated the location of the knife used by Resident 2 to injure Resident 1 was not known.
During a review of facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, last reviewed on 4/2024, the P&P indicated, All allegations are thoroughly investigated. The administrator initiates investigations The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR - a feder...
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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 Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level I Screening (preliminary screening to identify individuals potentially needing specialized services due to mental illness or intellectual/developmental disabilities) was completed for one of four sampled residents (Resident 2).
This deficient practice had the potential to result in a delay of necessary care and services to Resident 2.
Findings:
During a review of resident 2 ' s PASSR Level I Screening, dated 7/12/2024, the PASSR Level I Screening indicated Resident 2 did not have serious mental diagnoses. The PASRR Level I Screening also indicated Resident 2 did not require PASRR Level II Screening (a comprehensive evaluation to confirm the diagnosis and determine appropriate placement and [NAME]).
During a review of Resident 2 ' s admission Record (undated), the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), schizophrenia, and hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (loss of blood flow to a part of the brain) affecting right dominant side.
During a review of Resident 2 ' s admission Diagnosis Worksheet, dated 7/23/2024, the admission Diagnosis Worksheet indicated Resident 2 had diagnoses of stroke, asthma (a condition that causes swelling and narrowing of airways causing difficulty in breathing), hypertension (high blood pressure), and anxiety.
During a review of Resident 2 ' s admission Minimum Data Set (MDS - resident assessment tool), dated 7/25/2024, the admission MDS indicated Resident 2 was diagnosed with anxiety disorder.
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 was diagnosed with depression (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and anxiety disorder.
During a review of Resident 2 ' s History and Physical (H&P), dated 7/22/2024, the H&P indicated Resident 2 had the mental capacity to understand and make decisions.
During a review of Resident 2 ' s care plan, initiated on 3/17/2025, the care plan indicated Resident 2 had a mood challenge related to anxiety disorder, psychosis, and depression.
During a concurrent interview and record review with MDS Specialist on 3/22/2024 at 2:42 p.m., Resident 2 ' s Initial Psychiatric Evaluation, dated 9/25/2024 was reviewed. The Initial Psychiatric Evaluation indicated Resident 2 had diagnoses of Psychotic disorder and had episodes of delusions (having false or unrealistic beliefs) and hallucinations (a sensory experience that appears real but is not based on actual external stimuli). The MDS Specialist stated Level 1 PASRR Screening should have been completed for Resident 2.
During an interview on 3/22/2025 at 6:45 p.m. with the Director of Nursing (DON), the DON stated PASRR Screening provide the recommended behavioral interventions and care residents need. The DON stated PASRR Level I Screening should have been completed for Resident 2. The DON also stated the facility ' s failure could potentially cause delay in provision of necessary care to Resident 2.
During a review of the current facility-provided policy and procedure (P&P) titled, Subject: PASRR, dated 9/26/23, the P&P indicated status change Level I PASRR screening should be completed for a resident if there is a change in psychiatric diagnoses or if there is a discrepancy between PASRR diagnoses and diagnoses given by the attending physician or psychiatrist.
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 F0583
(Tag F0583)
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 confidential personal information of four ...
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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 confidential personal information of four of four sampled residents (Resident 9, Resident 10, Resident 11, and Resident 12) were protected by failing to:
1. Ensure Resident 9 ' s narcotic (a drug or other substances that affects mood or behavior) sheet was not left unattended, facing the hallway, on Nurse Station 3 ' s Telephone Orders Only bin.
2. Ensure the clinical records of Resident 10, Resident 11, and Resident 12 were not left unattended on Nurse Station 3 computer.
These deficient practices had the potential to violate Resident 9, Resident 10, Resident 11, and Resident 12's rights for privacy and confidentiality of personal and medical records.
Findings:
1. During a record review of Resident 9 ' s admission Record, the admission Record indicated the facility admitted the resident on 11/11/2021 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), essential hypertension (an abnormally high blood pressure that was not a result of a medical condition), and anxiety disorder (persistent and excessive worry that interferes with daily activities).
During a record review of Resident 9 ' s Minimum Data Set (MDS – a resident assessment tool), dated 2/13/2025, the MDS indicated Resident 9 ' s cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were intact.
During a record review of Resident 9 ' s Physician Order, dated 2/12/2024, the Physician Order indicated tramadol hydrochloride (a medication used to treat moderate to severe pain and was from a group of medicines called narcotics) 50 milligrams (mg – unit of measurement) one tablet every six hours as needed for pain.
During a concurrent observation and interview on 3/21/2025 at 9:04 a.m. with Registered Nurse (RN) 2, RN 2 stated Resident 9 ' s narcotic sheet was in the Telephone Orders Only bin at the nurse station 3. Observed Resident 9 ' s information on the narcotic sheet was facing the hallway. RN 2 stated that Resident 9 ' s information was visible to visitors, other residents, and to the facility staff that were not involved in Resident 9 ' s care. RN 2 stated visitors, other residents, and facility staff had the potential for unauthorized access to Resident 9 ' s clinical records. RN 2 stated the facility failed to ensure Resident 9 ' s right for privacy was protected.
2. During a record review of Resident 10 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/27/2025 with diagnoses including type 2 diabetes mellitus, essential hypertension, and muscle weakness.
During a record review of Resident 10 ' s MDS, dated [DATE], the MDS indicated Resident 10 ' s cognitive skills for daily decision making was moderately impaired.
During a record review of Resident 11 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/21/2025 with diagnoses including type 2 diabetes mellitus, essential hypertension, and muscle weakness.
During a record review of Resident 11 ' s MDS, dated [DATE], the MDS indicated Resident 11 ' s cognitive skills for daily decision making was intact.
During a record review of Resident 12 ' s admission Record, the admission Record indicated the facility admitted the resident on 11/28/2023 with diagnoses including type 2 diabetes mellitus, essential hypertension, and muscle weakness.
During a record review of Resident 12 ' s MDS, dated [DATE], the MDS indicated Resident 12 ' s cognitive skills for daily decision making was moderately impaired.
During a concurrent observation and interview on 3/21/2025 at 9:04 a.m. with RN 2, observed nurse station 3 ' s computer had Resident 10, Resident 11, and Resident 12 ' s clinical records on the screen. RN 2 stated the nurse station 3 computer screen indicated the access belonged to Licensed Vocational Nurse (LVN) 4, an 11 p.m. to 7 a.m. shift nursing staff. RN 2 stated Residents 10, 11, and 12 ' s clinical information was left unattended and had the potential for unauthorized access from other facility staff that were not involved on the residents ' care, visitors, and other outside agencies. RN 2 stated the facility failed to ensure Residents 10, 11, and 12 ' s right for privacy was protected.
During a record review of the facility ' s Policy and Procedure (PnP) titled, Electronic Medical Records, last reviewed on 4/2025, the PnP indicated only authorized persons who have been issued a password and user ID code will be permitted access to the electronic medical records system. The PnP indicated the medical records system safeguards the prevent unauthorized access of electronic protected health information (e-PHI). These safeguards included administrative, technical, and physical safeguards.
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 F0712
(Tag F0712)
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 a face-to-face visit (a required in-person meeting between a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a face-to-face visit (a required in-person meeting between a healthcare provider and a resident) was made by a physician or alternate visits by a Nurse Practitioner (NP) was conducted timely according to the facility ' s policy and procedure on Physician Visits for three of four sampled residents (Resident 5, Resident 6, and Resident 8).
This deficient practice had the potential to result in an undetected decline in Residents 5, 6, and 8's medical, health or psychosocial conditions and can lead to a delay in the necessary provision of care, treatment, and services.
Findings:
During a record review of Resident 5 ' s admission Record, the admission Record indicated the facility admitted the resident on 12/10/2024 with diagnoses including cellulitis (a bacterial infection of the skin and tissues, causing redness, swelling, and pain) of the left upper extremity (shoulder, arm and leg), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and muscle weakness.
During a record review of Resident 5 ' s Attending Progress Note, dated 11/21/2024, the Attending Progress Note indicated NP 1 visited and assessed the resident. The note did not indicate that the Attending Physician (MD) visited Resident 5.
During a record review of Resident 5 ' s Minimum Data Set (MDS - a resident assessment tool), dated 12/24/2024, the MDS indicated Resident 5 ' s cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact.
During a record review of Resident 5 ' s History and Physical (H&P), dated 12/11/2024, the H&P indicated MD 1 and NP 2 visited and assessed the resident. There was no documented H&P or Attending Progress Note in Resident 5 ' s electronic health record (EHR) and printed medical records after 12/11/2024.
During a record review of Resident 6 ' s admission Record, the admission Record indicated the facility admitted the resident on 7/8/2024 with diagnoses including type 2 diabetes mellitus, cystitis (inflammation of the bladder [a hallow organ that stores urine in the body]), and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities).
During a record review of Resident 6 ' s MDS, dated [DATE], the MDS indicated Resident 6 ' s cognitive skills for daily decision making were intact.
During a record review of Resident 6 ' s H&P, dated 7/8/2024, the H&P indicated NP 3 visited and assessed the resident. The note did not indicate that MD 2 visited Resident 6. There was no documented H&P or Attending Progress Note in Resident 6 ' s EHR and printed medical records after 7/8/2024.
During a record review of Resident 8 ' s admission Record, the admission Record indicated the facility admitted the resident on 6/8/2023 with diagnoses including type 2 diabetes mellitus, essential hypertension (an abnormally high blood pressure that was not a result of a medical condition), and anxiety disorder (persistent and excessive worry that interferes with daily activities).
During a record review of Resident 8 ' s MDS, dated [DATE], the MDS indicated Resident 8 ' s cognitive skills for daily decision making were intact.
During a record review of Resident 8 ' s H&P, dated 12/20/2024 and 3/7/2025, the H&P indicated MD 1 and NP 2 visited and assessed the resident. There was no documented H&P or Attending Progress Note in Resident 8 ' s EHR and printed medical records for 1/2025 and 2/2025.
During an interview on 3/21/2025 at 9:04 a.m. and a concurrent record review of Resident 5, Resident 6, and Resident 8 ' s H&Ps and Attending Physician Notes, reviewed with Registered Nurse (RN) 2, RN 2 stated there were no documented evidence that Resident 8 ' s MD visited the resident on 1/2025 and 2/2025. RN 2 stated a physician ' s progress notes should be in the residents ' medical records. RN 2 stated no documented physician progress notes indicated the MD did not assess the resident. RN 2 stated the residents ' condition had the potential to worsen. RN 2 stated the facility failed to ensure the attending physicians visited the residents and documented the visit according to the facility ' s policy and procedure.
During an interview on 3/21/2025 at 5:15 p.m. with the Director of Nursing (DON), the DON stated the physician progress notes were proof that the MD assessed the residents and verified the residents ' medications were accurate. The DON stated the staff involved in the residents ' care had the potential to make inconsistent or inaccurate medical decisions that had the potential to cause harm to the residents.
During a record review of the facility ' s Policy and Procedure (PnP) titled, Physician Visits, last reviewed on 4/2024, the PnP indicated the attending physician must visit his/her patients at least once every 30 days for the first 90 days following the resident ' s admission and then at least every 60 days thereafter. The policy indicated that after the first 90 days, if the attending physician determines that a resident need not be seen by him every 30 days, an alternate schedule of visits may be established, but not to exceed every 60 days. A physician assistant or NP may make alternate visits after the initial 90 days following admission.
During a record review of the facility ' s PnP titled, Attending Physician Responsibilities, last reviewed on 4/2024, the PnP indicated the Attending Physician will visit the residents in an timely The PnP indicated the MD will provide progress notes in a timely manner for placement in the medical record. The PnP indicated the note should either be written of entered at the time of the visit or should be returned to the facility for placement on the chart within one week.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical records of three of four sampled resident ' s (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 ensure the medical records of three of four sampled resident ' s (Resident 5, Resident 6, and Resident 7) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:
1. Ensure Resident 5 and Resident 7 ' s physician telephone orders were dated and signed.
2. Ensure Resident 5, Resident 6, and Resident 7 ' s Attending Physician (MD) reviewed and signed the residents ' Order Summary every month.
3. Ensure Resident 6 ' s medical records do not contain blank worksheet forms and blank consent forms with Nurse Practitioner's (NP) signatures.
These deficient practices had the potential for inaccurate medical interventions and inaccurate information on Residents 5, 6, and 7 ' s medical records.
Findings:
a. During a record review of Resident 5 ' s admission Record, the admission Record indicated the facility admitted the resident on 12/10/2024 with diagnoses including cellulitis (a bacterial infection of the skin and tissues, causing redness, swelling, and pain) of the left upper extremity (shoulder, arm and leg), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and muscle weakness.
During a record review of Resident 5 ' s Physician Order for oxycodone-acetaminophen (a medication used to relieve severe pain) 10-325 milligrams (mg – unit of measurement) and tramadol hydrochloride (a medication used to relieve moderate to severe pain), dated 12/10/2024, the order did not indicate the physician ' s signature and the date the physician orders were signed. The transcribed physician ' s order in the electronic health record (EHR) indicated the communication method (the method the order was received) for the physician orders were through telephone.
During a record review of Resident 5 ' s Minimum Data Set (MDS – a resident assessment tool), dated 12/24/2024, the MDS indicated Resident 5 ' s cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact.
During an interview on 3/20/2025 at 12:34 p.m. and concurrent record review of Resident 5 ' s Order Summary, dated 12/10/2025, reviewed with Licensed Vocational Nurse (LVN) 3, the Order Summary did not indicate a physician ' s signature and date Resident 5 ' s orders were signed. MD 1 signed Resident 5 ' s Order Summary on 9/4/2024. LVN 3 stated MD 1 ' s signature on the Order Summary indicated MD 1 approved the listed orders for Resident 5. LVN 3 stated the medical records staff were responsible to ensure the physicians signed Resident 5 ' s physician telephone orders and the resident ' s Order Summary. LVN 3 stated unsigned physician ' s orders had the potential for Resident 5 ' s unapproved and inaccurate orders.
During an interview on 3/21/2025 at 10:45 a.m. with the Health Information Director (HID), the HID stated she was responsible for ensuring the facility audits were done timely and the residents ' medical records were complete. The HID stated she was responsible to ensure the MDs sign the residents ' medical records. The HID stated the physicians should not sign blank consent forms. The HID stated there should be three months of printed and signed resident ' s Order Summary in the residents ' medical records. The HID stated incomplete resident medical records had the potential for residents to receive inaccurate and incomplete care. The HID stated the facility failed to ensure the residents ' medical records were complete and accurate.
During an interview on 3/21/2025 at 5:15 p.m. with the Director of Nursing (DON), the DON stated Resident 5 and Resident 7 ' s physician telephone orders and Order Summary were not signed. The DON stated the MDs should review and sign the Order Summary for Resident 5 and Resident 7 every month. The DON stated unsigned physician orders had the potential for resident harm due to inaccurate or incorrect orders. The DON stated the facility failed to follow the telephone order policy and failed to ensure the physician telephone orders and the residents ' Order Summary were signed and dated.
During a record review of the facility ' s Policy and Procedure (PnP) titled, Medication and Treatment Orders, reviewed on 4/2024, the PnP indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. The PnP indicated verbal orders must be signed by the prescriber at his or her next visit.
During a record review of the facility ' s PnP titled, Telephone Orders, last reviewed on 4/2024, the PnP indicated verbal telephone orders may be accepted from each resident ' s Attending Physician. The PnP indicated telephone orders must be countersigned by the physician during his or her next visit.
During a record review of the facility ' s PnP titled, Charting and Documentation, last reviewed on 4/2024, the PnP indicated that documentation in the medical record will be objective, complete, and accurate.
During a record review of the facility ' s PnP titled, Attending Physician Responsibilities, last reviewed on 4/2024, the PnP indicated the physician will periodically review all medications prescribed for the resident The PnP indicated the physician will verify accuracy of verbal orders when they are given and will authenticate, co-sign, and date them in a timely manner no later than the next visit to the resident.
b. During a record review of Resident 6 ' s admission Record, the admission Record indicated the facility admitted the resident on 7/8/2024 with diagnoses including type 2 diabetes mellitus, cystitis (inflammation of the bladder [a hallow organ that stores urine in the body]), and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities).
During a record review of Resident 6 ' s MDS, dated [DATE], the MDS indicated Resident 6 ' s cognitive skills for daily decision making was intact.
During an interview on 3/20/2025 at 12:55 p.m. and concurrent record review of Resident 6 ' s medical records, reviewed with LVN 3, Resident 6 ' s medical records did not have a printed and signed Order Summary. Resident 6 ' s medical records indicated a physician ' s signature, signed by the NP, on the following blank forms:
1. One set of admission Diagnosis Worksheet.
2. Two sets of Facility Verification of Informed Consents.
3. One set of Certification and Recertification for Medicare A Skilled Nursing Facility.
4. One set of MD Query on Malnutrition form.
LVN 3 stated Resident 6 ' s Order Summary should be in the resident ' s medical records. LVN 3 stated MD 2 should sign Resident 6 ' s Order Summary every month to indicate that MD 2 approved the orders required for Resident 6 ' s care. LVN 3 stated the Facility Verification of Informed Consents were consents used for residents that required psychotropic medications (medications used to stabilize or improve mood, mental status, or behaviors) and restraints. LVN 3 stated Resident 6 ' s physicians should sign the resident ' s medical record forms after it was completed. LVN 3 stated signed blank forms and consents had the potential for Resident 6 to receive inappropriate or wrong care.
During an interview on 3/21/2025 at 10:45 a.m. with the Health Information Director (HID), the HID stated she was responsible for ensuring the facility audits were done timely and the residents ' medical records were complete. The HID stated she was responsible to ensure the MDs sign the residents ' medical records. The HID stated the physicians should not sign blank consent forms. The HID stated there should be three months of printed and signed resident ' s Order Summary in the residents ' medical records. The HID stated incomplete resident medical records had the potential for residents to receive inaccurate and incomplete care. The HID stated the facility failed to ensure the residents ' medical records were complete and accurate.
During an interview on 3/21/2025 at 5:15 p.m. with the Director of Nursing (DON), the DON stated Resident 5 and Resident 7 ' s physician telephone orders and Order Summary were not signed. The DON stated the MDs should review and sign the Order Summary for Resident 5 and Resident 7 every month. The DON stated unsigned physician orders had the potential for resident harm due to inaccurate or incorrect orders. The DON stated the facility failed to follow the telephone order policy and failed to ensure the physician telephone orders and the residents ' Order Summary were signed and dated.
During a record review of the facility ' s PnP titled, Charting and Documentation, last reviewed on 4/2024, the PnP indicated that documentation in the medical record will be objective, complete, and accurate.
During a record review of the facility ' s PnP titled, Attending Physician Responsibilities, last reviewed on 4/2024, the PnP indicated the physician will periodically review all medications prescribed for the resident .The PnP indicated the physician will verify accuracy of verbal orders when they are given and will authenticate, co-sign, and date them in a timely manner no later than the next visit to the resident.
c. During a record review of Resident 7 ' s admission Record, the admission Record indicated the facility admitted the resident on 12/11/2009 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), epilepsy (a condition that affects the brain and causes frequent seizures [sudden, uncontrolled body movements and changes in behavior that occurs because of abnormal electrical activity in the brain]), and depression.
During a record review of Resident 7 ' s MDS, dated [DATE], the MDS indicated Resident 7 ' s cognitive skills for daily decision making was intact.
During a record review of Resident 7 ' s Physician Order for Lotensin (a medication used to treat high blood pressure), dated 1/23/2025, did not indicate the physician ' s signature and the date the physician orders were signed. The transcribed physician ' s order in the EHR indicated the communication method for the physician orders were by telephone.
During an interview on 3/21/2025 at 9:04 a.m. and concurrent record review of Resident 7 ' s Order Summary, dated 9/4/2024, reviewed with Registered Nurse (RN) 2, RN 2 stated the printed Order Summary in Resident 7 ' s medical record was the MD 1 signed and dated Resident 7 ' s Order Summary on 9/4/2024. RN 2 stated Resident 7 ' s medical records should have the printed and signed Order Summary for the last three months. RN 2 stated the medical records staff were responsible to ensure Resident 7 ' s medical records were complete and accurate. RN 2 stated Resident 7 ' s medical record was inaccurate and incomplete.
During an interview on 3/21/2025 at 10:45 a.m. with the Health Information Director (HID), the HID stated she was responsible for ensuring the facility audits were done timely and the residents ' medical records were complete. The HID stated she was responsible to ensure the MDs sign the residents ' medical records. The HID stated the physicians should not sign blank consent forms. The HID stated there should be three months of printed and signed resident ' s Order Summary in the residents ' medical records. The HID stated incomplete resident medical records had the potential for residents to receive inaccurate and incomplete care. The HID stated the facility failed to ensure the residents ' medical records were complete and accurate.
During an interview on 3/21/2025 at 5:15 p.m. with the Director of Nursing (DON), the DON stated Resident 5 and Resident 7 ' s physician telephone orders and Order Summary were not signed. The DON stated the MDs should review and sign the Order Summary for Resident 5 and Resident 7 every month. The DON stated unsigned physician orders had the potential for resident harm due to inaccurate or incorrect orders. The DON stated the facility failed to follow the telephone order policy and failed to ensure the physician telephone orders and the residents ' Order Summary were signed and dated.
During a record review of the facility ' s Policy and Procedure (PnP) titled, Medication and Treatment Orders, reviewed on 4/2024, the PnP indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. The PnP indicated verbal orders must be signed by the prescriber at his or her next visit.
During a record review of the facility ' s PnP titled, Telephone Orders, last reviewed on 4/2024, the PnP indicated verbal telephone orders may be accepted from each resident ' s Attending Physician. The PnP indicated telephone orders must be countersigned by the physician during his or her next visit.
During a record review of the facility ' s PnP titled, Charting and Documentation, last reviewed on 4/2024, the PnP indicated that documentation in the medical record will be objective, complete, and accurate.
During a record review of the facility ' s PnP titled, Attending Physician Responsibilities, last reviewed on 4/2024, the PnP indicated the physician will periodically review all medications prescribed for the resident The PnP indicated the physician will verify accuracy of verbal orders when they are given and will authenticate, co-sign, and date them in a timely manner no later than the next visit to the resident.
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to implement policy and procedure on safeguarding of all prescribed medications for one of three sampled residents (Resident 3) ...
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Based on observation, interview, and record review, the facility failed to implement policy and procedure on safeguarding of all prescribed medications for one of three sampled residents (Resident 3) by failing to ensure Resident 3's prescribed medication was stored in the medication cart of the nursing station where Resident 3 was located.
This deficient practice had the potential for non-authorized access to Resident 3's medications.
Findings:
During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 2/21/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), essential hypertension (an abnormally high blood pressure that was not a result of a medical condition), and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities).
During a record review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 11/27/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were intact.
During a concurrent observation and interview on 1/28/2025 at 9:20 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 opened the first top drawer at nurse station 400 and observed a medication container labeled Airshield (a medication brand name) dietary supplement with Resident 3's name and room number. LVN 1 stated Resident 3 was a current resident in the facility. LVN 1 stated medications should be placed inside the locked medication cart or inside the locked medication room.
During a follow up interview on 1/28/2025 at 10:35 a.m. and a concurrent record review of Resident 3's medical records, reviewed with LVN 1, LVN 1 stated Resident 3's Physician Order did not indicate an order for Airshield dietary supplement. LVN 1 stated medications that were discontinued should be disposed inside the locked medication room. LVN 1 stated residents' medications stored in an unlocked nurse station drawers had the potential for another resident to ingest the medication and result I adverse effects (unwanted and undesirable effects of a medication).
During an interview on 1/28/2025 at 2:40 p.m. with the Director of Nursing (DON), the DON stated Resident 3's discontinued medication should be inside the locked medication room. The DON stated other residents had the potential to have access to Resident 3's medication and cause the other resident adverse effects. The DON stated the facility failed to follow the policy and procedures on medication storage.
During a review of the facility's policy and procedure (PnP) titled, Storage of Medications, last reviewed on 4/2024, the PnP indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The PnP indicated discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. The PnP indicated compartments containing drugs and biologicals are locked when not in use. The PnP indicated unlocked medication carts are not left unattended.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors by failing to ensure the physician orders were followed. Resident 1's medication dose was not clarified with the attending physician.
This deficient practice placed Resident 1 at risk for medication administration error that had the potential to result in difficulty in breathing.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 9/23/2021 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), and muscle weakness.
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/20/2025, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were intact.
During an observation and concurrent interview on 1/28/2025 at 9:24 a.m. with Licensed Vocational Nurse 1 (LVN 1), observed Resident 1's medication box indicated Atrovent (a medication used to relax muscles in the airway and increases air flow to the lungs) 17 micrograms (mcg - unit of measurement) inhaler. LVN 1 stated Resident 1's medication label indicated one puff by mouth every 24 hours as needed for shortness of breath, wheezing, or COPD.
During an interview on 1/28/2025 at 9:26 a.m. and a concurrent record review of Resident 1's Physician Orders, reviewed with LVN 1 the Physician Orders, dated 1/25/2025, indicated Atrovent HFA aerosol solution (a substance released in very fine mist) 17 mcg four puffs inhale orally every 24 hours as needed for shortness of breath, wheezing, or COPD. LVN 1 stated Resident 1's Medication Administration Record (MAR) indicated the resident did not receive any dose of Atrovent since the resident was readmitted from General Acute Care Hospital 1 (GACH 1). LVN 1 stated Resident 1's Nursing Note, dated 1/25/2025 at 3:23 p.m., indicated Registered Nurse 2 (RN 2) received a pharmacy note that indicated the resident's Atrovent HFA four puffs exceed the maximum single dose of 2 puffs. LVN 1 stated there was no physician order for Resident 1's Atrovent HFA one puff by mouth every 24 hours. LVN 1 stated the Resident 1 had the potential to receive the wrong medication dose.
During an interview on 1/28/2025 at 2:40 p.m. with the Director of Nursing (DON), the DON stated RN 2 did not verify Resident 1's medication dosage and frequency with the attending physician. The DON stated Resident 1 had the potential to receive a wrong dose of the medication. The DON stated the facility failed to ensure medications were clarified with the attending physician.
During a record review of the facility's policy and procedure (PnP) titled, Medication Administration, last reviewed on 4/2024, the PnP indicated any dose or order that appears inappropriate considering the resident's age, condition, or diagnosis is verified with the attending physician before processing. The PnP indicated the facility pharmacy will not process a medication order if it is unclear or confusing, until the clarification was made.
Jan 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain a system-wide method for pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, ...
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Based on interview and record review, the facility failed to maintain a system-wide method for pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of nine sampled residents (Resident 1) by failing to account for the exact whereabouts of Resident 1 ' s controlled substance (narcotics) medication.
This deficient practice increases the risks for mishandling of a controlled substance increases the risks of diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of medications, staff working in an impaired state, or accidental exposure of controlled substances to other residents possibly resulting in respiratory depression (the inability to breathe) leading to hospitalization or death.
Findings:
A review of Resident 1 ' s admission Record indicated an admission date of 12/23/2024 with the diagnoses of aftercare following surgery for neoplasm (an abnormal growth of tissue in the body that can be cancerous or noncancerous), muscle weakness, and general anxiety disorder (condition of persistent worrying interfering with day-to-day life).
A review of Resident 1 ' s Minimum Data Set ([MDS] resident assessment tool) dated 10/30/2024 indicated Resident 1 to be with no impairment in thought process and could understand and answer questions.
A review of Physician ' s Orders for Resident 1 indicated a controlled substance medication order on 12/27/2024 at 5:02 p.m. for Lorazepam Oral Tablet 0.5 milligrams ([mg] unit of weight measurement), to be given one (1) tablet by mouth at bedtime for anxiety manifested by feelings of nervousness.
On 1/16/2025 at 1 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, At the start of every shift, we (Licensed Nurses) have to verify the narcotics count with the incoming Licensed Nurse with the outgoing nurse. We need both staff to sign that it was verified. It is important to count the narcotics because they are controlled medications, and we need to prevent the residents from taking them. Controlled medications can reduce the breathing rate and result in the patient being non-responsive, then the patient can die if they are not breathing.
On 1/16/2025 at 4:46 p.m., during an interview with the Director of Nursing (DON), DON stated that through the facility ' s internal investigation, Resident 1 ' s narcotic medication and the count sheet were missing and never found, and the exact number of tablets missing cannot be determined. DON stated the facility needs to account for controlled substances, indicating that whoever accesses it can have an overdose by respiratory depression described as a decrease in the breathing rate or have an adverse reaction with other medications causing the possibility of hospitalization or death.
A review of the facility-provided undated policy and procedure titled Controlled Substances, indicated, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. The policy also stated, The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; d. Destruction, waste and return to pharmacy records.
Based on interview and record review, the facility failed to maintain a system-wide method for pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of nine sampled residents (Resident 1) by failing to account for the exact whereabouts of Resident 1's controlled substance (narcotics) medication.
This deficient practice increases the risks for mishandling of a controlled substance increases the risks of diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of medications, staff working in an impaired state, or accidental exposure of controlled substances to other residents possibly resulting in respiratory depression (the inability to breathe) leading to hospitalization or death.
Findings:
A review of Resident 1's admission Record indicated an admission date of 12/23/2024 with the diagnoses of aftercare following surgery for neoplasm (an abnormal growth of tissue in the body that can be cancerous or noncancerous), muscle weakness, and general anxiety disorder (condition of persistent worrying interfering with day-to-day life).
A review of Resident 1's Minimum Data Set ([MDS] resident assessment tool) dated 10/30/2024 indicated Resident 1 to be with no impairment in thought process and could understand and answer questions.
A review of Physician's Orders for Resident 1 indicated a controlled substance medication order on 12/27/2024 at 5:02 p.m. for Lorazepam Oral Tablet 0.5 milligrams ([mg] unit of weight measurement), to be given one (1) tablet by mouth at bedtime for anxiety manifested by feelings of nervousness.
On 1/16/2025 at 1 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, At the start of every shift, we (Licensed Nurses) have to verify the narcotics count with the incoming Licensed Nurse with the outgoing nurse. We need both staff to sign that it was verified. It is important to count the narcotics because they are controlled medications, and we need to prevent the residents from taking them. Controlled medications can reduce the breathing rate and result in the patient being non-responsive, then the patient can die if they are not breathing.
On 1/16/2025 at 4:46 p.m., during an interview with the Director of Nursing (DON), DON stated that through the facility's internal investigation, Resident 1's narcotic medication and the count sheet were missing and never found, and the exact number of tablets missing cannot be determined. DON stated the facility needs to account for controlled substances, indicating that whoever accesses it can have an overdose by respiratory depression described as a decrease in the breathing rate or have an adverse reaction with other medications causing the possibility of hospitalization or death.
A review of the facility-provided undated policy and procedure titled Controlled Substances, indicated, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. The policy also stated, The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; d. Destruction, waste and return to pharmacy records.
Based on interview and record review, the facility failed to maintain a system-wide method for pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of nine sampled residents (Resident 1) by failing to account for the exact whereabouts of Resident 1's controlled substance (narcotics) medication.
This deficient practice increases the risks for mishandling of a controlled substance increases the risks of diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of medications, staff working in an impaired state, or accidental exposure of controlled substances to other residents possibly resulting in respiratory depression (the inability to breathe) leading to hospitalization or death.
Findings:
A review of Resident 1's admission Record indicated an admission date of 12/23/2024 with the diagnoses of aftercare following surgery for neoplasm (an abnormal growth of tissue in the body that can be cancerous or noncancerous), muscle weakness, and general anxiety disorder (condition of persistent worrying interfering with day-to-day life).
A review of Resident 1's Minimum Data Set ([MDS] resident assessment tool) dated 10/30/2024 indicated Resident 1 to be with no impairment in thought process and could understand and answer questions.
A review of Physician's Orders for Resident 1 indicated a controlled substance medication order on 12/27/2024 at 5:02 p.m. for Lorazepam Oral Tablet 0.5 milligrams ([mg] unit of weight measurement), to be given one (1) tablet by mouth at bedtime for anxiety manifested by feelings of nervousness.
On 1/16/2025 at 1 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, At the start of every shift, we (Licensed Nurses) have to verify the narcotics count with the incoming Licensed Nurse with the outgoing nurse. We need both staff to sign that it was verified. It is important to count the narcotics because they are controlled medications, and we need to prevent the residents from taking them. Controlled medications can reduce the breathing rate and result in the patient being non-responsive, then the patient can die if they are not breathing.
On 1/16/2025 at 4:46 p.m., during an interview with the Director of Nursing (DON), DON stated that through the facility's internal investigation, Resident 1's narcotic medication and the count sheet were missing and never found, and the exact number of tablets missing cannot be determined. DON stated the facility needs to account for controlled substances, indicating that whoever accesses it can have an overdose by respiratory depression described as a decrease in the breathing rate or have an adverse reaction with other medications causing the possibility of hospitalization or death.
A review of the facility-provided undated policy and procedure titled Controlled Substances, indicated, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. The policy also stated, The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; d. Destruction, waste and return to pharmacy records.
Dec 2024
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of the quality of life for one ...
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Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of the quality of life for one of three sampled residents (Resident 1) by failing to ensure Resident 1's preference to self-administer a medication was honored.
This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/8/2024 with diagnoses including type 2 diabetes mellitus, depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were intact.
During a record review of Resident 1's Physician Orders, dated 8/9/2024, the Physician Orders indicated Trulicity (a medication used in the treatment of type 2 diabetes) 3 milligrams (mg - unit of measurement) / 0.5 milliliter (ml - unit of measurement) subcutaneous (under all the layers of the skin) pen injector, given in the morning every Sunday for diabetes mellitus.
During an interview on 12/24/2024 at 9:18 a.m. and a concurrent record review of Resident 1's Physician Orders, created on 8/9/2024 and revised on 12/8/2024, reviewed with Registered Nurse 1 (RN 1), the Physician Orders indicated the clinician (licensed nurses) were to administer the Trulicity 3mg to Resident 1. RN 1 stated there was no order for Resident 1 to self-administer the Trulicity 3mg.
During an interview on 12/24/2024 at 10:44 a.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated Resident 1 preferred to self-administer the Trulicity 3 mg medication.
During an interview on 12/24/2024 at 11:03 a.m. with LVN 4, LVN 4 stated Resident 1 preferred to self-administer the Trulicity 3 mg. LVN 4 stated on 9/2024 or 10/2024 (LVN 4 was not able to recall the exact date) she informed RN 1 regarding Resident 1's preference to self-administer the medication. LVN 4 stated the licensed nurse should perform an assessment of Resident 1's ability to self-administer a medication. LVN 4 stated the licensed nurse should provide an education to the resident and obtain a physician order to self-administer a medication. LVN 4 stated the licensed nurse should create a care plan that addressed Resident 1's self-administration of medication. LVN 4 was not able to provide documented evidence that Resident 1's reassessment, resident education, training, and physician order for self-administration of medication. LVN 4 was not able to provide documented evidence of Resident 1's care plan on resident preference to self-administer the medication.
During an interview on 12/24/2024 at 11:40 a.m. with the Director of Nursing (DON), the DON stated the licensed nurses should initiate the process to determine Resident 1's ability to self-administer as soon as the licensed nurse was informed about the resident's preference. The DON stated it was Resident 1's right to self-administer the medication after the self-administration of medication process had been completed. The DON stated the facility failed to ensure the resident's right to self-administer a medication was done according to the facility's policy.
During a record review of the facility's policy and procedure (PnP) titled, Self-Administration of Medications, last reviewed on 4/2024, the PnP indicated residents have the right to self-administer medications if the interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) had determined that it is clinically appropriate and safe for the resident to do so. The PnP indicated as part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate for the resident.
During a record review of the facility's PnP titled, Resident Rights, last reviewed on 4/2024, the PnP indicated Federal and State laws guarantee certain basic rights to all residents in the facility. These rights include the resident's right to self-determination, be informed of and participate in his care planning and treatment, and to self-administer medication if the IDT determines it is safe.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a comprehensive assessment was done for one of three sampled residents (Resident 1) by failing to reassess Resident 1 for self-admin...
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Based on interview and record review, the facility failed to ensure a comprehensive assessment was done for one of three sampled residents (Resident 1) by failing to reassess Resident 1 for self-administration of medications.
This deficient practice had placed Resident 1 at risk for medication administration error that had the potential to result in injection site infection and underdosage of the medication.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/8/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were intact.
During a record review of Resident 1's Physician Orders, dated 8/9/2024, the Physician Orders indicated Trulicity (a medication used in the treatment of type 2 diabetes) 3 milligrams (mg - unit of measurement) / 0.5 milliliter (ml - unit of measurement) subcutaneous (under all the layers of the skin) pen injector, given in the morning every Sunday for diabetes mellitus.
During an interview on 12/24/2024 at 9:18 a.m. and a concurrent record review of Resident 1's Physician Orders, created on 8/9/2024 and revised on 12/8/2024, reviewed with Registered Nurse 1 (RN 1), the Physician Orders indicated the clinician (licensed nurses) to administer the Trulicity 3mg to Resident 1. RN 1 stated there was no order for Resident 1 to self-administer the Trulicity 3mg.
During an interview on 12/24/2024 at 11:03 a.m. and a concurrent record review of Resident 1's Medication Administration Record (MAR) dated 8/1/2024 to 12/31/2024, reviewed with Licensed Vocational Nurse 4 (LVN 4), the MAR indicated Resident 1 received Trulicity 3 mg from LVN 4 eight times. LVN 4 stated Resident 1 preferred to self-administer the Trulicity 3 mg. LVN 4 stated Resident 1 self-administered Trulicity 3 mg seven out of the eight times LVN 4 was assigned to administer the medication. LVN 4 stated the licensed nurse should perform an assessment of Resident 1's ability to self-administer a medication. LVN 4 stated the licensed nurse should provide an education to the resident and obtain a physician order to self-administer a medication. LVN 4 stated the licensed nurse should create a care plan that addressed Resident 1's self-administration of medication. LVN 4 stated Resident 1 did not have an assessment that indicated the resident may self-administer medications. LVN 4 was not able to provide documented evidence that Resident 1 had education and training on self-administering medications. LVN 4 stated Resident 1 had the potential for infection and complications from incorrect administration of a medication.
During an interview on 12/24/2024 at 11:40 a.m. with the Director of Nursing (DON), the DON stated self-administration of medications require a licensed nurse assessment. The DON stated the licensed nurse should provide Resident 1 the required bedside training and document the resident's ability to self-administer the medication. Resident 1 was not reassessed for self-administration of medications. The DON was not able to provide documented evidence that Resident 1 received education and training on self-administration of Trulicity 3 mg. The DON stated Resident 1 had the potential to experience discomfort if the resident was not assessed and trained on medication self-administration. The DON stated the facility failed to follow the facility's policy and procedure on self-administration of medications.
During a record review of the facility's policy and procedure (PnP) titled, Self-Administration of Medications, last reviewed on 4/2024, the PnP indicated residents have the right to self-administer medications if the interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) had determined that it is clinically appropriate and safe for the resident to do so. The PnP indicated as part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate 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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident...
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Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1) was created and implemented that addressed Resident 1's self -administration of medication.
This deficient practice had placed Resident 1 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/8/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were intact.
During a record review of Resident 1's Physician Orders, dated 8/9/2024, the Physician Orders indicated Trulicity (a medication used in the treatment of type 2 diabetes) 3 milligrams (mg - unit of measurement) / 0.5 milliliter (ml - unit of measurement) subcutaneous (under all the layers of the skin) pen injector, given in the morning every Sunday for diabetes mellitus.
During an interview on 12/24/2024 at 9:18 a.m. and a concurrent record review of Resident 1's Physician Orders, created on 8/9/2024 and revised on 12/8/2024, reviewed with Registered Nurse 1 (RN 1), the Physician Orders indicated the clinician (licensed nurses) were to administer the Trulicity 3mg to Resident 1. RN 1 stated there was no order for Resident 1 to self-administer the Trulicity 3mg.
During an interview on 12/24/2024 at 11:03 a.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated the licensed nurse should perform an assessment of Resident 1's ability to self-administer a medication. LVN 4 stated the licensed nurse should provide an education to the resident and obtain a physician order to self-administer a medication. LVN 4 stated the licensed nurse should create a care plan that addressed Resident 1's self-administration of medication. LVN 4 stated Resident 1 did not have a care plan to self-administer Trulicity 3 mg medication. LVN 4 stated without a care plan on self-administration of medication, Resident 1 had the potential for infection and complications from incorrect administration of a medication.
During an interview on 12/24/2024 at 11:40 a.m. with the Director of Nursing (DON), the DON stated there was no care plan created for Resident 1 that addressed the resident's ability to self-administer a medication. The DON stated Resident 1 had the potential to receive inconsistent care. The DON stated the facility failed to follow the facility's policy and procedure on self-administration of medication that included a creation of a resident care plan.
During a record review of the facility's policy and procedure (PnP) titled, Comprehensive Person-Centered Care Plans, last reviewed on 4/2024, the PnP indicated the interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) in conjunction with the resident and family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The PnP indicated the comprehensive, person-centered care plan describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
During a record review of the facility's PnP titled, Self-Administration of Medications, last reviewed on 4/2024, the PnP indicated if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a physician order to self-administer Trulicity (a medication used in the treatment o...
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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a physician order to self-administer Trulicity (a medication used in the treatment of type 2 diabetes mellitus [a chronic condition that affects the way the body processes blood sugar]).
This deficient practice had the potential to create confusion in the delivery of care and services to Resident 1.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/8/2024 with diagnoses including type 2 diabetes mellitus, depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were intact.
During a record review of Resident 1's Physician Orders, dated 8/9/2024, the Physician Orders indicated Trulicity (a medication used in the treatment of type 2 diabetes) 3 milligrams (mg - unit of measurement) / 0.5 milliliter (ml - unit of measurement) subcutaneous (under all the layers of the skin) pen injector, given in the morning every Sunday for diabetes mellitus.
During an interview on 12/24/2024 at 9:18 a.m. and a concurrent record review of Resident 1's Physician Orders, created on 8/9/2024 and revised on 12/8/2024, reviewed with Registered Nurse 1 (RN 1), the Physician Orders indicated the clinician (licensed nurses) were to administer the Trulicity 3mg to Resident 1. RN 1 stated there was no order for Resident 1 to self-administer the Trulicity 3mg.
During an interview on 12/24/2024 at 11:03 a.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 1 did not have a physician order to self-administer the Trulicity 3 mg.
During an interview on 12/24/2024 at 11:40 a.m. with the Director of Nursing (DON), the DON stated self-administration of medications required a physician order. The DON was not able to provide documented evidence of a physician order for Resident 1 to self-administer Trulicity 3 mg. The DON stated the facility failed to follow the facility's policy and procedure on self-administration of medications and physician orders.
During a record review of the facility's policy and procedure (PnP) titled, Self-Administration of Medications, last reviewed on 4/2024, the PnP indicated residents have the right to self-administer medications if the interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) had determined that it is clinically appropriate and safe for the resident to do so. The PnP indicated as part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate for the resident.
During a record review of the facility's PnP titled, Telephone Orders, last reviewed on 4/2024, indicated the entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors by failing to ensure the physician orders we...
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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors by failing to ensure the physician orders were followed. Resident 1 was allowed to self-administer a medication without an order for self-administration.
This deficient practice placed Resident 1 at risk for medication administration error that had the potential to result in uncontrolled blood sugar.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/8/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were intact.
During a record review of Resident 1's Physician Orders, dated 8/9/2024, the Physician Orders indicated Trulicity (a medication used in the treatment of type 2 diabetes) 3 milligrams (mg - unit of measurement) / 0.5 milliliter (ml - unit of measurement) subcutaneous (under all the layers of the skin) pen injector, given in the morning every Sunday for diabetes mellitus.
During an interview on 12/24/2024 at 9:18 a.m. and a concurrent record review of Resident 1's Physician Orders, created on 8/9/2024 and revised on 12/8/2024, reviewed with Registered Nurse 1 (RN 1), the Physician Orders indicated the clinician (licensed nurses) to administer the Trulicity 3mg to Resident 1. RN 1 stated there was no order for Resident 1 to self-administer the Trulicity 3mg.
During an interview on 12/24/2024 at 11:03 a.m. and a concurrent record review of Resident 1's Medication Administration Record (MAR) dated 8/1/2024 to 12/31/2024, reviewed with Licensed Vocational Nurse 4 (LVN 4), the MAR indicated Resident 1 received Trulicity 3mg from LVN 4 eight times. LVN 4 stated Resident 1 preferred to self-administer the Trulicity 3mg. LVN 4 stated Resident 1 self-administered Trulicity 3 mg seven out of the eight times LVN 4 was assigned to administer the medication. LVN 4 stated Resident 1 required a physician order before the resident was allowed to self-administer a medication. LVN 4 stated Resident 1 did not have a physician order to self-administer Trulicity 3 mg.
During an interview on 12/24/2024 at 11:40 a.m. with the Director of Nursing (DON), the DON stated self-administration of medications required a physician order. The DON stated Resident 1 did not have a physician order to self-administer Trulicity 3 mg. The DON stated the facility failed to follow the policy and procedure on self-administering medications.
During a record review of the facility's policy and procedure (PnP) titled, Self-Administration of Medications, last reviewed on 4/2024, the PnP indicated residents have the right to self-administer medications if the interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) had determined that it is clinically appropriate and safe for the resident to do so. The PnP indicated as part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate for the resident.
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (intent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (intentional bodily injury) for one of eight sampled residents (Resident 1) when on 12/3/2024, Resident 7 witnessed Resident 2 hit Resident 1 left arm causing a scratch using Resident 2's left hand.
This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility.
Findings:
During a review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted the resident on 4/27/2024, with a diagnosis of saddle embolus of pulmonary artery with acute cor pulmonale (a life-threatening condition that occurs when a large blood clot blocks the main pulmonary artery, preventing blood flow to both lungs).
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/1/2024, the MDS indicated that resident had moderate cognitive (relating to the mental process involved in knowing, learning, and understanding things) impairment (damage).
During a review of Resident 1' Care Plan, dated 12/3/2024, the Care Plan indicated Resident 1 was at risk for emotional and psychological distress related to resident to resident incident and sustained a scratch in the left forearm. The Care Plan indicated Resident 1 was at risk for left forearm infection, acute pain, and further decline in activity of daily living.
During a review of Resident 1's Change in Condition (COC) Evaluation, dated 12/3/2024, the COC Evaluation indicated Resident 1 had a scratch to the left forearm related to a physical altercation with another resident (Resident 2).
During a review of Resident 2's Record of Admission, the Record of admission indicated the facility initially admitted the resident on 10/8/2012 and readmitted on [DATE], with a diagnosis of hemiplegia (weakness or paralysis on one side of the body) following cerebral infarction (a stroke is a brain attack that happens when blood flow to the brain is stopped) affecting right dominant side.
During a review of Resident 2's History & Physical (H&P), dated 9/19/2023, the H&P indicated that resident had the capacity to understand and make decisions. The H&P indicated Resident 2 can make needs known but cannot make medical decisions.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated resident had severe cognitive impairment.
During a review of Resident 2's COC Evaluation, dated 12/3/2024, the COC Evaluation indicated Resident 2 had a verbal/physical altercation with another resident (Resident 1). THE COC Evaluation indicated Resident 2 was sent out to the general acute care hospital (GACH) emergency room for behavioral management.
During a review of Resident 7's Record of Admission, the Record of admission indicated the facility admitted the resident on 11/11/2021, with a diagnosis of type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel).
During a review of Resident 7's H&P, dated 8/2/2023, the H&P indicated resident had the capacity to understand and make decisions.
During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 had intact cognition.
During an interview on 12/17/2024 at 1:55 p.m., Resident 7 stated that Resident 1 was sitting in her wheelchair by the door around 1:30 p.m. to 2 p.m. Then Resident 1 wheeled herself close to Resident 2 in front of Resident 2's closet and Resident 1 keep saying amen, amen, amen. Resident 7 stated that Resident 2 told Resident 1 to shut up and Resident 1 did not stop. Resident 7 stated that Resident 1 reached out and hit Resident 2's right arm then Resident 2 hit back at Resident 1 in her right arm that left a scratch in Resident 1's left arm.
During an interview on 12/18/2024 at 11:03 a.m., License Vocational Nurse 3 (LVN 3) stated that Resident 7 witnessed that Resident 1 and Resident 2 hit each other's arm. LVN 3 stated this was considered physical abuse.
During an interview on 12/18/2024 at 1:41 p.m., the Administrator (Admin) stated that based on their facility policy and procedure this was considered as physical abuse.
During a review of the facility policy and procedure titled, Abuse Prevention Program, with last reviewed date of 4/2024, the policy indicated our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusions, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.
During a review of the facility policy and procedure titled, Abuse and Neglect - Clinical Protocol, with last reviewed date of 4/2024, the policy indicated Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.
Oct 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to report an allegation of employee to resident abuse within two hours to the State Survey Agency (SSA), the Ombudsman (an advocate for reside...
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Based on interview and record review, the facility failed to report an allegation of employee to resident abuse within two hours to the State Survey Agency (SSA), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and law enforcement as per its policies on abuse for one of three sampled residents (Resident 1).
This deficient practice had the potential to place Resident 1 at risk for further abuse.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 2/15/2023, with diagnoses that included displaced intertrochanteric fracture of right femur (a hip fracture that occurs when the bone breaks between the bumps at the top of the thigh bone, and the injured leg is noticeably shortened and externally rotated), dysphagia (swallowing difficulty) and essential hypertension (persistently raised blood pressure with no secondary cause identified).
During a record review of Resident 1 ' s History and Physical (H&P), dated 1/6/2024, the H&P indicated Resident 1 had capacity to understand and make decisions.
During a record review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 8/21/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required moderate assistance from staff for activities of daily living (ADL-oral and personal hygiene).The MDS indicated Resident 1 was always incontinent (unable to control) of bowel and bladder functions.
During a record review of Resident 1 ' s Change in Condition Evaluation (CIC), dated 10/23/2024, the CIC indicated at 10 p.m., Certified nursing Assistant 1 (CNA 1) was rough on Resident 1. The CIC indicated the physician was notified on 10/24/2024 at 12 midnight.
During a record review of Resident 1 ' s Progress Notes, dated 10/23/2024, timed at 11:21 p.m., the Progress Notes indicated on 10/23/2024, at 9:30 p.m., Resident 1 was yelling and screaming. The Progress Notes indicated Licensed Vocational Nurse 1 (LVN 1) called Family Member 1 (FM 1) due to a language barrier and FM 1 translated that CNA 1 was rough on Resident 1. The Progress Note indicated LVN 1 notified Registered Nurse 1 (RN 1).
During a record review of LVN 1 ' s written statement, the written statement indicated on 10/23/2024, at 9:30 p.m., Resident 1 kept yelling in foreign language and appeared upset. The written statement indicated LVN 1 called FM 1 and FM 1 translated that CNA 1 did not attend to Resident 1, CNA 1 turned the call light off, CNA 1 was rough to Resident 1 and CNA 1 hit Resident 1 in the head with a dirty incontinent brief. The written statement indicated LVN 1 reported to RN 1 immediately.
During an interview on 10/31/2024, at 9:22 a.m., with Resident 1 and translated by LVN 2, Resident 1 stated CNA 1 changed her (Resident 1) incontinent brief and applied the powder on her private area as per her (Resident 1) request. Resident 1 stated she (Resident 1) lowered CNA 1 ' s hand down to prevent the powder from going to her (Resident 1) eyes. Resident 1 stated CNA 1 hit her (Resident 1) right wrist, CNA 1 turned around and took the used incontinent brief on the floor and threw it and hit her (Resident 1) head. Resident 1 stated she (Resident 1) informed FM 1.
During an interview on 10/31/2024, at 9:39 a.m., with RN 1, RN 1 stated LVN 1 borrowed the RN Supervisors phone and called FM 1 to translate what Resident 1 was saying. RN 1 stated LVN 1 reported that CNA 1 threw the incontinent brief at Resident 1. RN 1 stated Resident 1 claimed CNA 1 was rough. RN 1 stated LVN 1 wrote a written statement, but she (RN 1) did not read it and just placed it in the Director of Staff Development (DSD ' s) office. RN 1 stated she did not report the allegation to the Director of Nursing (DON) and did not report to the Administrator (ADM) that night of 10/23/2024, but did report the following day 10/24/2024, to the DSD and Assistant Director of Nursing (ADON). RN 1 stated she did not call the law enforcement and stated if no injury from allegation of abuse the report can be done in 24 hours. RN 1 stated she did not notify the SSA and Ombudsman that night of 10/23/2024.
During an interview on 10/31/2024, at 9:58 a.m., with the ADON, the ADON stated there was a delay in reporting allegation of abuse. ADON stated RN 1 should have reported to SSA, Ombudsman and law enforcement on 10/23/2024. The ADON stated the facility ' s policy for abuse was to report any allegation of abuse within two hours. The ADON stated the importance of reporting within two hours was to initiate the abuse investigation and for residents ' safety to prevent emotional distress.
During an interview on 10/31/2024, at 10:19 a.m., with LVN 1, LVN 1 stated on 10/23/2024, at 9:30 p.m., she (LVN 1) heard yelling and found Resident 1 upset. LVN 1 stated she (LVN 1) called FM 1 and FM 1 informed her (LVN 1) that CNA 1 was rough on Resident 1 and that CNA 1 grabbed the wet incontinent brief and hit Resident 1 in the head. LVN 1 stated she (LVN1) reported to RN 1 because Resident 1 had allegation of abuse.
During an interview on 10/31/2024, at 11:10 a.m., with the Administrator (ADM), the ADM stated there was a delay in communicating and allegation of abuse should have been reported immediately. The ADM stated allegation is allegation and RN 1 need to communicate for proper investigation. The ADM stated their policy for reporting abuse is to report within two hours.
During a review of facility ' s policy and procedure (PP) titled, Abuse Investigation and Reporting, dated 2001, and last reviewed on 4/24/2024, the PP indicated, Reporting:
1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:
a. The State licensing/certification agency responsible for surveying/licensing the facility.
b. The local/State Ombudsman.
c. The Resident ' s Representative (Sponsor) of Record.
d. Adult Protective Services (where state law provides jurisdiction in long-term care).
e. Law enforcement officials.
f. The resident ' s Attending Physician; and
g. The facility Medical Director.
2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:
a. Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards of practice for one of three sampled resi...
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Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards of practice for one of three sampled residents (Resident 1).
This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1's medical record.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 2/15/2023, with diagnoses that included displaced intertrochanteric fracture of right femur (a hip fracture that occurs when the bone breaks between the bumps at the top of the thigh bone, and the injured leg is noticeably shortened and externally rotated), dysphagia (swallowing difficulty) and essential hypertension (persistently raised blood pressure with no secondary cause identified).
During a record review of Resident 1 ' s History and Physical (H&P), dated 1/6/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a record review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 8/21/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required moderate assistance from staff for activities of daily living (ADL-oral and personal hygiene). The MDS indicated Resident 1 was always incontinent (unable to control) of bowel and bladder functions.
During a record review of Resident 1 ' s Progress Notes dated 10/23/2024, timed at 11:21 p.m., the Progress Notes indicated on 10/23/2024, at 9:30 p.m., Resident 1 was yelling and screaming. The Progress Notes indicated Licensed Vocational Nurse 1 (LVN 1) called Family Member 1 (FM 1) due to a language barrier and FM 1 translated that CNA 1 was rough on Resident 1. The Progress Note indicated LVN 1 notified Registered Nurse 1 (RN 1).
During a record review of LVN 1 ' s written statement, the written statement indicated on 10/23/2024, at 9:30 p.m., Resident 1 kept yelling in foreign language and appeared upset. The written statement indicated LVN 1 called FM 1 and FM 1 translated that CNA 1 did not attend to Resident 1, CNA 1 turned the call light off, CNA 1 was rough to Resident 1 and CNA 1 hit Resident 1 in the head with a dirty incontinent brief. The written statement indicated LVN 1 reported to RN 1 immediately.
During an interview on 10/31/2024, at 9:22 a.m., with Resident 1 and translated by LVN 2, Resident 1 stated CNA 1 changed her (Resident 1) incontinent brief and applied the powder on her private area as per her (Resident 1) request. Resident 1 stated she (Resident 1) lowered CNA 1 ' s hand down to prevent the powder from going to her (Resident 1) eyes. Resident 1 stated CNA 1 hit her (Resident 1) right wrist, CNA 1 turned around and took the used incontinent brief on the floor and threw it and hit her (Resident 1) head. Resident 1 stated she (Resident 1) informed FM 1.
During an interview on 10/31/2024, at 10:19 a.m., with LVN 1, LVN 1 stated on 10/23/2024, at 9:30 p.m., she (LVN 1) heard yelling and found Resident 1 upset. LVN 1 stated she (LVN 1) called FM 1 and FM 1 informed her (LVN 1) that CNA 1 was rough on Resident 1 and that CNA 1 grabbed the wet incontinent brief and hit Resident 1 in the head. LVN 1 stated she (LVN1) reported to RN 1 because Resident 1 had allegation of abuse.
During a concurrent interview and record review on 10/31/2024 at 11:27 a.m., with the ADON, Resident 1 ' s Progress Note dated 10/23/2024, timed at 11:21 p.m., and LVN 1 ' s written statement was reviewed. The ADON stated LVN 1 did not document that in Resident 1 ' s medical record that FM 1 translated Resident 1 ' s report that CNA 1 had hit Resident 1 in the head with a dirty incontinent brief. The ADON stated medical records should be complete and accurate.
During a record review of facility ' s policy and procedure (PP) titled, Charting and Documentation undated and last reviewed on 4/2024, the PP indicated, 2. The following information is to be documented in the resident medical record:
a. Objective observations.
b. Medications administered.
c. Treatments or services performed.
d. Changes in the resident's condition.
e. Events, incidents or accidents involving the resident; and
f. Progress toward or changes in the care plan goals and objectives.
3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.
Oct 2024
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (delibe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of 11 sampled residents (Resident 9). On 10/17/2024 at 7:30 p.m., Certified Nursing Assistant 4 (CNA 4) witnessed Resident 10's left arm was around Resident 9's neck from behind, while Resident 10 punched Resident 9 with his (Resident 10) right closed fist multiple times on the face while Resident 9 was sitting on the wheelchair watching television (TV) in their (Resident 9 and Resident 10's) room.
This deficient practice resulted in Resident 9 being subjected to physical abuse by Resident 10 while under the care of the facility. Resident 9 sustained swelling on the lips with bleeding and pain. Based on the Reasonable Person Concept (the usual behavior of an average person under the same circumstances), due to Residents 9's severely impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and medical condition, an individual subjected to physical abuse may have physical pain, psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for own self).
Findings:
During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 9/16/2024 with diagnoses including aphasia (a disorder that makes it difficult to speak) following cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), abnormalities of gait (the manner of walking or moving on foot) and mobility (the ability to move freely and easily), and muscle weakness.
During a review of Resident 9's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/23/2024, the MDS indicated Resident 9's cognition was severely impaired. The MDS indicated Resident 9 had little interest or pleasure in doing things, feeling down, depressed (in a state of general unhappiness), or hopeless for 12 to 14 days or nearly every day. The MDS indicated Resident 9 felt bad about self, a failure or let self or family down for 12 to 14 days or nearly every day. The MDS indicated Resident 9 sometimes felt lonely or isolated from those around the resident.
During a review of Resident 9's Change in Condition (COC - a significant change in resident's health status) Evaluation, dated 10/17/2024, the COC Evaluation indicated that on 10/17/2024 at 7:30 p.m., the resident (Resident 9) received physical abuse from another resident (Resident 10). The COC Evaluation indicated Resident 9 was found sitting in a wheelchair watching TV when Resident 10 hit Resident 9 on the face. Resident 9 sustained swelling on the lips and had a five out of 10 pain level on the pain scale (a common scale that uses numbers from zero to 10, with zero representing no pain and 10 representing the worst possible pain). The COC Evaluation indicated Resident 9 required ice pack to be placed on the swollen lip. The COC Evaluation indicated Resident 9's Attending Physician was notified at 8:41 p.m. on 10/17/2024.
During a review of Resident 9's Progress Notes, dated 10/17/2024, the Progress Notes (documented by Licensed Vocational Nurse 2 [LVN 2]) indicated that on 10/17/2024 at 7:30 p.m., he (LVN 2) was called inside Resident 9 and Resident 10's room (Resident 9 and Resident 10 were roommates). Resident 9's Progress Note indicated CNA 4 witnessed Resident 10 held Resident 9's neck from behind. The Progress Notes indicated Resident 10 punched Resident 9 multiple times with a closed fist (the Progress Note did not indicate which fist). The Progress Notes indicated Resident 9 was noted with swollen lips.
During a review of Resident 10's admission Record, the admission Record indicated the facility admitted Resident 10 on 3/31/2021 with diagnoses including encephalopathy (damage or disease that affects the brain), rhabdomyolysis (the breakdown of muscle tissue that leads to the release of muscle fiber into the blood), and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought).
During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10's cognition was severely impaired.
During a review of Resident 10's Care Plan (untitled), last revised on 1/4/2023, indicated the resident (Resident 10) was noted with aggressive behavior and getting upset for no reason. The interventions included were to re-direct resident behavior and for the resident not to hurt others or damage property.
During a review of Resident 10's History and Physical (HP), dated 4/29/2024, the HP indicated the resident had the capacity to understand and make decisions.
During a review of Resident 10's Care Plan (untitled), last revised on 9/30/2024, indicated the resident (Resident 10) had mood swings with poor impulse control. The Care Plan interventions included were to monitor, record, and report to the physician risk for harming others, increased anger, labile mood (rapid, often exaggerated changes in mood occur), or agitation (a state of anxiety or nervous excitement), feeling threatened by others or thoughts of harming someone.
During a review of Resident 10's Physician Orders, dated 9/28/2024, the Physician Order indicated to monitor behavior episodes of sudden outburst of anger and tally with hashmark for each episode on the Medication Administration Record (MAR - a report detailing the medications administered to a resident) every shift.
During a review of Resident 10's MAR, dated 10/1/2024 to 10/31/2024, the MAR indicated that on 10/14/2024 on the 11 p.m. to 7 a.m. shift, Resident 10 had two episodes of anger outburst.
During a review of Resident 10's COC Evaluation, dated 10/17/2024, the COC Evaluation indicated on 10/17/2024 at 7:30 p.m., Resident 10 was witnessed behind Resident 9 while hitting the resident (Resident 9) on the face multiple times.
During an interview on 10/24/2024 at 9:58 a.m. with Resident 9, Resident 9 stated another resident punched him on the face. Resident 9 was not able to provide other information about the incident.
During a telephone interview on 10/24/2024 at 10:12 a.m. with CNA 4, CNA 4 stated she (CNA 4) heard Resident 9 yelling inside the resident's room. CNA 4 stated she (CNA 4) then went inside Resident 9's room and found Resident 9 sitting on a wheelchair. CNA 4 stated Resident 10's left arm was around Resident 9's neck, while Resident 10 punched Resident 9's face with his (Resident 10) right closed fist multiple times. CNA 4 stated that Resident 10's punches were hits and misses on Resident 9's right cheek, right jaw, and right side of the mouth area. CNA 4 stated Resident 9 and Resident 10 were separated. CNA 4 stated Resident 9 had blood (amount not indicated) in the mouth and in the right lower lip that required an ice pack. CNA 4 stated Resident 10 punching Resident 9 is physical abuse.
During a telephone interview on 10/24/2024 at 12:26 p.m. with LVN 2, LVN 2 stated he heard someone screaming at Station 1 LVN 2 stated that when he (LVN 2) entered inside Resident 9 and Resident 10's room, both residents were already separated. LVN 2 stated CNA 4 witnessed Resident 10 punching Resident 9 on the face. LVN 2 stated Resident 9's middle part of the lower lip was bleeding requiring an ice pack to be placed on the lips to prevent swelling and to stop the bleeding. LVN 2 stated Resident 10 had a history of aggressive behavior towards another resident. LVN 2 stated that Resident 10 punching Resident 9 is physical abuse.
During an interview on 10/24/2024 at 12:38 p.m. with the Director of Nursing (DON), the DON stated residents should be free from abuse. The DON stated the physical act of intentionally punching a person is physical abuse. Resident 10 punching Resident 9 was considered as an abuse. The DON stated the facility failed to prevent the physical act of abuse from happening between Resident 9 and Resident 10.
During a review of the facility's policy and procedure (PnP) titled, Abuse, Neglect (fail to care properly), Exploitation (the act of using someone or something unfairly for your own advantage) and Misappropriation (to steal something that you have been trusted to take care of and using it for yourself) Prevention Program, last reviewed on 4/2024, the PnP indicated the resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The PnP indicated that it included freedom from . verbal, mental, sexual, or physical abuse The PnP indicated the facility objective to protect residents from abuse by anyone including .b. other residents.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of 11 sampled residents (Resident 1, Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of 11 sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) were provided a safe and homelike environment. The facility failed to:
1a. Ensure Resident 1, 2, and 3 had a restroom with functioning plumbing system.
b. Ensure safe and private alternative restrooms were provided for Residents 1,2, and 3's toileting needs.
2. Ensure Resident 4 was informed that other residents were directed to use Resident 4's restroom.
These deficient practices resulted in Residents 1,2,3, and 4 not having a homelike comfortable and safe environment.
Findings:
During an interview on 10/23/2024 at 9:05 a.m. with the Director of Maintenance (DM), the DM stated station 4 had clogged drains since 1 p.m. on 10/22/2024. The DM stated resident rooms 1, 2, 3, and shower rooms B and C were affected by the clogged drains.
During a concurrent observation and interview on 10/23/2024 at 9:27 a.m. with Maintenance Assistant 1 (MA 1), MA 1 stated the DM ran a 50-foot drain snake to unclog the drain and was unsuccessful. Observed the drain in the middle right side of station 4's patio had visible liquid up to the brim of the open pipe drain. MA 1 stated that the liquid on the pipe had been like that since yesterday, 10/22/2024. Observed station 4 shower rooms B and C with visible stagnant water pooling around the drain.
1. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 11/9/2021 with diagnoses including dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).
During a review of Resident 2's Care Plan on self-care performance, initiated on 11/19/2021, the Care Plan indicated the resident had self-care performance deficit related to activity intolerance and impaired balance. The Care Plan interventions indicated Resident 2 prefers to use the toilet for toileting needs.
During a review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/23/2024, the MDS indicated Resident 2's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The MDS indicated Resident 2 required the use of a walker or wheelchair for mobility (ability to move). The MDS indicated Resident 2 required supervision or assistance in walking 10 feet, toileting, and personal hygiene. The MDS indicated Resident 2 did not attempt and perform walking 50 feet with two turns before the current illness.
2. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/30/2023 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area) affecting the right dominant side, repeated falls, and essential hypertension.
During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 required the use of a wheelchair for mobility. The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) in toileting, and personal hygiene.
3. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 8/8/2024 with diagnoses including abnormalities with gait (the pattern that a person walks) and mobility, muscle weakness, and essential hypertension.
During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognition was intact. The MDS indicated Resident 3 required the use of a walker or a wheelchair for mobility. The MDS indicated Resident 3 required moderate assistance (helper lifts or holds trunk or limbs and provides less than half the effort) in toileting hygiene and walking 10 feet. The MDS indicated Resident 3 did not attempt to walk 50 feet with two turns and to walk 150 feet due to medical condition or safety concerns.
4. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 2/21/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), essential hypertension, and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities).
During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognition was intact.
During an interview on 10/23/2024 at 9:39 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Residents 2, 1, and 3's restroom was not working and was clogged. CNA 2 stated she was not informed where to assist the residents in the affected room on the residents' toileting needs.
During an interview on 10/23/2024 at 9:45 a.m. with Licensed Vocational Nurse 1 (LVN 1) stated she was informed that residents in the room with a clogged drain were to use the occupied residents' room across nurse station 4. LVN 1 stated she was not informed if the residents in the room across nurse station 4 were aware that other residents were using their restroom. LVN 1 stated the residents' privacy and safety had the potential to be violated.
During concurrent interviews on 10/23/2024 at 9:48 a.m. with Resident 1 and CNA 2, Resident 1 stated CNA 2 assisted him to the restroom in another residents' room to use the toilet. CNA 2 stated she assisted Resident 1 to use the restroom in the residents' room across the nurse station 4.
During an interview on 10/23/2024 at 9:54 a.m. with Resident 2, Resident 2 stated the restroom had been clogged for three days. Resident 2 stated he was informed to use the restroom in another residents' room across nurse station 4 or the staff restroom at the end of station 4 hallway. Resident 2 stated the staff restroom required a code to enter. Resident 2 stated the facility staff did not provide the code to the staff restroom. Resident 2 stated it was inconvenient and unsafe to walk to another residents' room or down the end of the hallway in the middle of the night to use the toilet.
During an interview on 10/23/2024 at 10:02 a.m. with CNA 3, CNA 3 stated he saw other facility staffs assist residents to the residents' room across the nurse station 4 for the residents' toileting needs.
During an interview on 10/23/2024 at 12:06 p.m. with Resident 3, Resident 3 stated the restroom in the resident's room was clogged. Resident 3 stated the residents in the room affected with the clogged restroom drain were informed to use the restroom in the occupied residents' room across the nursing station 4 or the staff restroom at the end of station 4 hallway. Resident 3 stated the staff restroom required a code which the residents were not provided. Resident 3 stated the staff restroom was small and a walker or wheelchair would not fit inside. Resident 3 stated using another resident's restroom or walking to the end of the station 4 hallway to use the restroom was inconvenient and unsafe.
During an interview on 10/23/2024 at 2:39 p.m. with Resident 4, Resident 4 stated nobody informed the resident that other residents were using the restroom. Resident 4 stated the facility staff should inform the residents if residents other that the roommates were to use the restroom.
During an interview on 10/24/2024 at 11:04 a.m. with the Director of Nursing (DON), the DON stated she was not aware that the residents in the room with a clogged drain used another residents' restroom or the staff restroom for their toileting needs. The DON stated the residents in the room with a clogged drain should have been offered a temporary room change or a commode (a portable toilet not connected to plumbing that features a removable chamber). The DON stated the staff restroom was small and would not fit the walker or wheelchair of the residents. The DON stated the residents using a walker or a wheelchair was not safe to use the staff restroom. The DON stated the facility failed to provide a homelike environment for the residents. The DON stated the facility failed to ensure safety of the residents when using the staff restroom, and the facility failed to ensure privacy for the residents that occupied the room across the nurse station 4.
During a review of the facility's policy and procedure (PnP) titled, Homelike Environment, last reviewed on 4/2024, indicated residents were provided with a safe, clean, comfortable, and homelike environment The PnP indicated staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.
Oct 2024
30 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0806
(Tag F0806)
Someone could have died · 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 one of one sampled resident (Resident 13...
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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 one of one sampled resident (Resident 135) was not given food containing allergens (a substance that causes an allergic [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances] reaction) when on 10/8/2024, Resident 135, who was allergic to onions, was served baked beans containing onions for lunch.
This deficient practice resulted in Resident 135 being served baked beans containing onions which had the potential to result in a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (sudden loss of heart function, breathing, and consciousness [the state of being awake and aware of one's surroundings]) and/or death for Resident 135.
On 10/8/2024 at 4:03 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) situation in the presence of the Administrator (ADM) and the Director of Nursing (DON) for the facility's failure to ensure that facility staff did not provide food containing a known allergen to Resident 135.
On 10/11/2024 at 8:35 a.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) which included the following summarized actions:
1. On 10/8/2024, Resident 135 was assessed by a licensed nurse (Licensed Vocational Nurse 7 [LVN 7]) for signs and symptoms (s/s) of food allergies. No allergic reaction was observed.
2. On 10/8/2024, the DON notified Resident 135's primary physician indicating the resident was mistakenly served food (baked beans) containing onions during lunch on 10/8/2024.
3. On 10/8/2024, the Dietary Supervisor (DS) visited Resident 135 to discuss the resident's food allergies and food preferences.
4. On 10/8/2024, the DS conducted a review of all current resident's medical records residing in the facility with noted food allergies and there were no issues found.
5. On 10/8/2024, the DS conducted an in-service (staff training) with all dietary staff on the facility's Food Allergy Policy which included implementing colored meal tray card [a card that lists a resident's dietary needs, preferences, and restrictions] and reviewing menu or recipe to offer substitutes addressing food allergies.
6. On 10/8/2024, for higher visibility (how clear the food allergies can be noticed), green meal tray cards indicating food allergies were created for residents with food allergies.
7. On 10/8/2024, residents with food allergies were provided a green non-removable arm band with their names and food allergies.
8. On 10/8/2024, the Director of Staff Development (DSD) provided an in-service to the licensed nurses and Certified Nursing Assistants (CNAs) which included the green non-removable arm bands as visual identifier for residents who have food allergies.
9. On 10/9/2024, the Registered Dietitian (RD) reviewed current residents' medical records to ensure food allergies are up to date.
10. On 10/9/2024, the RD conducted a one to one (1:1- when one trainer works with one learner) in-service with the Cooks (Cooks 1 and [NAME] 2) and the DS regarding the facility policy on food allergies, food likes or dislikes, menu, recipes, and to accommodate food item substitution to address food allergies.
11. On 10/9/2024, before the breakfast service, the RD, the Cooks (Cooks 1 and [NAME] 2), and the DS conducted kitchen huddles (short, regular meeting where the staff discusses resident safety and plans for the day ahead) on menu, recipes, and meal substitution (if applicable) for residents with food allergies.
12. A list of residents and their food allergies will be posted in the kitchen meal preparation area to allow dietary staff to easily identify all residents' food allergies. The list of residents and their food allergies will be written in English and Spanish. Identified residents with food allergies will be served alternate meals.
13. The facility will implement a new menu system called Menus 2U which integrates Electronic Health Records (EHR - digital version of a resident's medical records stored in a computer) and ensures that all new dietary orders and food allergies are automatically entered into the facility's EHR. The software will include printing of the updated diet slip (includes diet orders, food/drink preferences, food allergies, special utensils, and meal instructions) for each meal by the DS or designee and the dietary staff will reference the meal preparation during meal tray line (an area where resident's food is assembled), avoiding inaccuracies, and identifying allergies. Included in the diet slip are the following:
a. Diet order
b. Diet consistency
c. Diet texture
d. Likes and dislikes
e. Food allergy
f. Beverage preferences
g. Tray instruction
h. Feed instructions
i. Special utensils.
14. Starting on 10/9/2024, the DS or designee will conduct a daily review of all current residents' medical records to ensure that residents with food allergies are included on the allergy list visibly posted during the meal tray line process.
15. Starting on 10/9/2024, the DS or designee will conduct daily huddles with all dietary staff in English and Spanish to discuss current residents with food allergy to ensure meals that will be served will not contain food allergies.
16. Starting on 10/9/2024, the DS or designee will conduct daily meal tray audit for allergies using the Tray line Supervisory Inspection Log every breakfast, lunch, and dinner meals and every 10 a.m., 2 p.m., and 8 p.m. snacks.
17. Licensed Nurses shall check meal trays for any food allergies, food dislikes, and preferences before serving the residents. Any discrepancy in accuracy on the meal prepared in comparison with the diet slip will be returned to the kitchen by the licensed nurse for correction and replacement.
18. The DS will conduct a review of food preferences and allergies upon admission, readmission, quarterly, and as needed. The Health Information Department will conduct an audit monthly to validate this process. Audit findings will be forwarded to the DON and to the ADM for further follow through.
19. The RD will conduct monthly review of residents with food allergies and update the list of residents and their food allergies as needed.
On 10/11/2024 at 3:21 p.m., while onsite and after verifying the facility's full implementation of the IJ removal plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presence of the DON.
Findings:
During a review of Resident 135's admission Record, the admission Record indicated the facility initially admitted Resident 135 on 10/1/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems), chronic viral hepatitis C (long term liver inflammation and infection), and essential hypertension (chronic elevation of blood pressure from an unknown cause).
During a review of Resident 135's Minimum Data Sheet (MDS - a federally mandated resident assessment tool) dated 10/5/2024, the MDS indicated Resident 135's cognition (ability to think and make decisions) was severely impaired. The MDS indicated Resident 135 needed set-up and clean-up assistance (helper sets up and cleans up, resident completes the activity) when eating.
During a review of Resident 135's Physician Orders dated 10/1/2024, the Physician Orders indicated to provide mechanical soft (a texture-modified diet that consists of foods that are soft and easy to chew and swallow) chopped texture (a food texture that is intended to be safe and easy to swallow) diet.
During a review of Resident 135's Allergy List dated 10/1/2024, the Allergy List indicated Resident 135 was allergic to onions.
During a review of Resident 135's Care Plan (undated), the Care Plan indicated Resident 135 has an allergy to onions. The Care Plan goal was for Resident 135 not to be served with food containing onions at any time. Resident 135's Care Plan included the following interventions:
o Inform staff or caregivers of resident's allergy.
o Label the Physician's Order Sheet, Medication Administration Record (MAR - a document of the medications administered to a resident), treatment sheet, and face sheet of Resident 135's allergy.
During a review of Resident 135's MAR dated 10/8/2024, the MAR indicated Resident 135 was allergic to onions.
During a review of the facility's daily spreadsheet titled Therapeutic Spreadsheet Cycle 4, dated 10/8/2024, the daily spreadsheet indicated residents on mechanical soft diet would include the following foods in the tray:
o
Ground barbecue pork (BBQ) three (3) ounces (oz, a unit of measurement)
o
Baked beans half (½) cup (c, a household measurement)
o
Finely chopped creamy coleslaw ½ c
o
Biscuit
o
Peach cobbler
o
Beverage eight (8) oz
During an observation of the meal tray line process on 10/8/2024 at 11:53 a.m., the trays with utensils, condiments, and meal tray tickets (includes resident's diet, allergy, likes/dislikes, food preferences) were set in the meal carts (used to transport or deliver the meal trays). Dietary Aide 1 (DA 1) announced the resident's diet textures, likes, and dislikes then the allergies. [NAME] 1 and [NAME] 2 dished out (distributed) the foods from the steamtable (food-holding equipment designed to keep hot foods at a safe holding temperature) to the plates. DA 1 checked the accuracy and completeness of each tray. The DS checked the accuracy of the trays before the meal carts came out of the kitchen.
During a review of Resident 135's meal tray ticket on 10/8/2024 at 12:25 p.m., Resident 135's meal tray ticket indicated Resident 135 was on mechanical soft diet, was allergic to onions, disliked salad and coleslaw, and preferred soup and juice.
During a concurrent observation and interview on 10/8/2024 at 12:25 p.m. at the kitchen with the DS, observed Resident 135's meal tray contained chopped pork with BBQ sauce, a bowl of beans with chopped onions, biscuit, cake, and juice. The DS stated Resident 135 did not get the soup as the dietary staff forgot to put the soup on the tray. The DS requested a vegetable soup from the dietary staff and placed the vegetable soup on Resident 135's tray. The DS stated Resident 135 was okay with cooked onions that was included in the vegetable soup. The SSA informed the DS that onions were listed as an allergy of Resident 135. The DS replaced the vegetable soup with clear broth for Resident 135.
During an observation on 10/8/2024 at 12:29 p.m. in the kitchen hallway, LVN 2 and LVN 3 checked the meal trays for Station 2's meal cart where Resident's 135 lunch tray was placed. LVN 3 read the diet list (a list of residents with diet, allergies, likes, and dislikes) and LVN 2 checked the meal tray and meal tray ticket for Resident 135's tray accuracy. LVN 2 and LVN 3 stated the meal trays for Station 2 residents were okay to distribute to Station 2. Resident 135's meal tray was served and was set on Resident 135's bedside table.
During an observation on 10/8/2024 at 12:39 p.m., in Resident 135's room, observed Resident 135's meal tray at bedside. Resident 135's meal tray had chopped pork with BBQ sauce, beans in a bowl with pieces of chopped onions, biscuit, clear broth, cake, and juice.
During an interview and a record review of the facility's recipe titled Baked Beans #2 on 10/8/2024 at 12:56 p.m. with [NAME] 1 and the Assistant Dietary Supervisor (ADS), [NAME] 1 stated with ADS interpreting in [NAME] 1's language that she (Cook 1) used only the recipe titled Baked Beans #2 for the baked beans. The Baked Beans #2 recipe indicated the following ingredients: pork and beans, light brown sugar, chopped onions, ketchup, and yellow mustard. [NAME] 1 stated she did not use the pork and beans and used the pinto beans from scratch instead. [NAME] 1 stated she then added ketchup, onions, brown sugar, and mustard. [NAME] 1 stated she did not prepare a separate recipe for any resident.
During an interview on 10/8/2024 at 12:59 p.m. with the DS, the DS stated that if Resident 135 consumed the food item with onions, he (Resident 135) would have food reactions such as rash (an area of the skin that has changes in texture or color and may look inflamed or irritated) and other allergic reactions.
During an interview on 10/8/2024 at 1:08 p.m. with Resident 135, Resident 135 stated he did not eat the beans on his meal tray because he was afraid that the beans had onions. Resident 135 stated the staff (unable to recall who) told him that the baked beans may have contained onions, and the meal tray was taken away from him by the staff (unable to recall who). Resident 135 stated his throat will swell up and close if he consumes onions.
During an interview on 10/9/2024 at 9:52 a.m. with DA 1, DA 1 stated his role in meal tray line was to announce the allergy and check the meal trays for accuracy with what the meal tray ticket indicated. DA 1 stated he did not know that the baked beans had onions as it was not specified on the spreadsheet or the menu. DA 1 stated it was important for the meal tray to be allergen-free for residents with food allergies because they (residents) could be in danger and could potentially cause death.
During an interview on 10/9/2024 at 11 a.m. with LVN 2 and LVN 3, LVN 2 stated they (LVN 2 and LVN 3) checked all the trays for accuracy, food dislikes, allergies, and diet types on 10/8/2024 for lunch meal. LVN 2 stated she checked the tray, meal tray tickets, and food on the meal tray and LVN 3 read and checked the diet list. LVN 2 stated they checked all the trays from Station 1 to Station 4. LVN 3 stated she (LVN 3) did not see any onions in any of the food served for Resident 135 and there was no way that they could know if onion was an ingredient in the baked beans.
During an interview on 10/10/2024 at 10:56 a.m. with the ADM, the ADM stated that he (ADM) needed to verify with [NAME] 1's interpreter (ADS) about the ingredient that she (Cook 1) used in cooking the baked beans as he (ADM) was told that [NAME] 1 stated she used onion powder.
During a review of the ADM's email on 10/10/2024 at 1:48 p.m., the ADM email indicated that he confirmed with the ADS who interpreted during [NAME] 1's interview on 10/8/2024, that [NAME] 1 stated she (Cook 1) used onion powder in the baked bean dish.
During an interview on 10/10/2024 at 2:09 a.m. with the RD, the RD stated the dietary staff should not serve any food items, derivatives, flavoring, powder, and all products containing a particular allergen. The RD stated residents with onion allergies should not get onions, onion derivatives, onion powder, onion flavor, and all onion products on their meal trays. The RD stated residents could have the same anaphylactic reactions (anaphylactic shock) if they (residents) consumed food and food products containing the food allergen.
During a concurrent interview and record review on 10/10/2024 at 2:34 p.m. with [NAME] 1 and the RD with the Interpreter's (translating [NAME] 1's language via phone) assistance, the facility's undated recipe titled Baked Beans #2 was reviewed. Baked Beans #2 had an ingredient of pork and beans, light brown sugar, chopped onions, and mustard. [NAME] 1 stated she did not use the pork and beans and used pinto beans for the baked bean dish. [NAME] 1 stated she used the ketchup, light brown sugar, and yellow mustard but did not use chopped onions. [NAME] 1 stated she used onion powder instead of chopped onions because she did not like the flavor of the onion but likes the onion powder when making the baked beans. [NAME] 1 stated she used onion powder and added one spoon to the baked beans using estimation on how the food would taste as it (recipe) did not indicate the amounts. [NAME] 1 stated she said onion to ADS who was interpreting in [NAME] 1's language during the interview on 10/8/2024 and never mentioned onion powder because she (Cook 1) forgot to say powder. [NAME] 1 stated raw onions were available in the kitchen on 10/8/2024. The RD stated the staff (unable to recall who) notified her of the substitution of onions to onion powder after the IJ was called. The RD stated she did not agree with the substitution of using onion powder for onions based on how [NAME] 1 felt about the flavor as it was not a standard of practice. The RD stated the onion powder could have more ingredients that would contain more food allergens. The RD stated the recipe must be followed to ensure residents got the nutrients that they needed and so they could be aware of the ingredients for food allergies.
During an interview on 10/11/2024 at 2:45 p.m. with the DS, the DS stated onion powder was a derivative of onion and residents could have same reaction if they were allergic to onions; hence, it (onion powder) should not be given on the meal tray.
During a review of the facility's product ingredient titled Ingredient Specification Onion dated 9/15/2024, the facility's product specification indicated, Description: Dehydrated onion (Allium cepa [common onion/bulb onion]) product prepared from fresh, sound, wholesome, first quality white onion.
During a review of the facility's policies and procedures (P&P) titled Food Allergies and Intolerances dated 4/2024, the P&P indicated, Residents with food allergies and/or intolerances are identified upon admission and offered food substitution of similar appeal and nutritional value. Steps are taken to prevent residents' exposure to the allergen.
General Guidelines:
1. Food Allergies are immune system responses to allergens (food). Immunoglobulin E ([NAME]) antibodies (type of protein in the body that are part of the immune system and play a role in allergic reactions) to foods attach to mast (white blood cells that are part of the body's immune system and act as the body's alarm system) cells in body tissue (e.g., skin, nose, throat, lungs, and gastrointestinal tract) and basophils (a type of white blood cell that help the body's immune system fight allergens) in blood. When allergens are eaten, the [NAME] antibodies attach to mast cells and basophils in certain sites and those cells produce histamine (chemical released by the body's immune system that causes many effects, including allergy symptoms), an inflammatory compound.
Assessment and Interventions:
o
Residents are assessed for history of food allergies and intolerances upon
admission and as part of the comprehensive assessment.
o
All residents reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident's care plan.
o
Meals for residents with severe food allergies are specifically prepared so that cross-contamination (the unintentional transfer of harmful bacteria or other
microorganisms from one food, utensil, or surface to another) with allergens does not occur.
o
Residents with food intolerances and allergies are offered appropriate substitutions for food that they cannot eat.
During a review of the facility's P&P titled Allergies dated 4/2024, the P&P indicated, Procedure: (1) Upon admission to the community resident allergies will be identified. These will be noted on the nutritional assessment that is completed on admission. (4) The resident's menu will be modified to eliminate foods to which the resident is allergic.
During a review of the facility's P&P titled Accurate Diet Service dated 4/2024, the P&P indicated Policy: Each resident will receive the proper diet as prescribed by their physician or qualified designee. Procedure: (1) Before each meal service, a Food and Nutrition Services Department employee will check the meal tray cards with master list to assure the correct diet order, consistency order, and liquid consistency order on the card. (2) Prior to serving the tray, the nurse aide must check the diet cart to assure that the correct meal tray is being served to the resident. If there is doubt, the charge nurse should be notified, and the chart checked for the current physician's order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach ...
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Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for one of six sampled residents (Resident 112) investigated under environment facility task.
The deficient practice had the potential to result in residents not being able to summon a health care worker for help as needed.
Findings:
During a review of Resident 112's admission Record (AR), the AR indicated the facility admitted the resident on 2/15/2024, and readmitted the resident on 2/29/2024, with diagnoses including encephalopathy (damage or disease that affects the brain) and anxiety disorder (a condition where a person has excessive and persistent feelings of fear, dread, and uneasiness).
During a review of Resident 112's Order Summary Report, dated 2/26/2024, the report indicated to place a yellow arm band on the resident for fall precaution and monitor for presence.
During a review of Resident 112's Care Plan (CP) titled The resident is high risk for falls related to gait (a manner of walking or moving on foot)/balance problems, incontinence, unaware of safety needs, last revised on 4/23/2024, the CP indicated an intervention to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.During a review of Resident 112's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/3/2024, the MDS indicated Resident 112 had the ability to make self-understood and to understand others. The MDS indicated Resident 112 was dependent and required substantial to maximal assistance in mobility and 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 Resident 112 had a fall since admission with no injury.
During a review of Resident 112's Nursing Fall Risk Evaluation (FRE), dated 9/3/2024, the FRE indicated the resident was assessed as a high risk for falls.
During a concurrent observation and interview on 10/8/2024, at 9:40 a.m., with Licensed Vocational Nurse 4 (LVN 4), Resident 112's call light button was observed dangling on the right side of the bed almost touching the floor. LVN 4 stated the resident cannot reach the call button as it is almost on the ground at the right side of the bed. LVN 4 stated the resident was a fall risk and reaching for the button on the floor could cause the resident to fall and sustain an injury.
During an interview on 10/11/2024, at 2:09 p.m., with the Director of Nursing (DON), the DON stated the staff should always ensure the call light is within reach of the resident so they can call for help when needed. The DON added the resident can fall while reaching for the call light when it is away from the resident.
During a review of the facility's recent policy and procedure (P&P) titled Answering the Call Light, last reviewed on 4/2024, the P&P indicated the purpose of this procedure is to ensure timely responses to the resident's requests and needs. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.
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** Based on observation, interview and record review, the facility failed to offer and assist the resident's choice to wear persona...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to offer and assist the resident's choice to wear personal clothing for one of one sampled resident (Resident 23) investigated under the Choices investigative area.
This deficient practice has the potential to result in a decline in the resident's self-esteem and self-worth.
Findings:
During a review of Resident 23's admission Record, the admission Record indicated the facility admitted the resident on 1/19/2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities).
During a review of Resident 23's MDS, dated [DATE], the MDS indicated the resident's preferences to choose what clothes to wear was very important. The MDS indicated the resident was able to make self understood and usually understood others. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with upper body dressing, lower body dressing, and putting on/taking off footwear.
During a review of Resident 23's activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) self-care performance deficit care plan, revised 2/1/2024, the care plan indicated the resident goals of not developing complications related to decreased ADL performance. The interventions included assisting the resident to choose simple comfortable clothing that enhances the resident's ability to dress self.
During an interview on 10/8/2024 at 3:22 p.m., Responsible Party 1 (RP 1) stated she has repeatedly requested the nursing staff (licensed nurses and certified nursing assistants) for Resident 23 to wear her night gown at night and not a hospital gown (a facility-provided robe worn by patients in a hospital). RP 1 stated the resident was wearing a hospital gown most of the time when she comes and visit the resident. RP 1 stated the resident has personal clothes to wear.
During a concurrent observation and interview, at Resident 23's bedside, on 10/9/2024 at 8:02 a.m., with CNA 13, CNA 13 stated she started her shift at 7:20 a.m. that day and she was the assigned CNA for Resident 23. CNA 13 stated she has not changed the resident yet. CNA 13 stated Resident 23 was wearing a hospital gown with a long-sleeve pink shirt underneath. CNA 13 stated Resident 23 wore the same clothes the previous afternoon and throughout the night.
During a concurrent observation and interview, at Resident 23's bedside, on 10/9/2024 at 4:20 p.m., with CNA 13, CNA 13 stated resident was wearing a green hospital gown. CNA 13 stated she changed Resident 23 into a new gown. CNA 13 stated Resident 23 had clothes in the closet. CNA 13 stated she would change the resident's clothes during the day shift, but because it was already after 3 p.m. she did not need to. CNA 13 stated she did not know Resident 23 had clothes in their closet. CNA 13 stated she did not check the resident's closet before putting on the hospital gown on Resident 23.
During an interview on 10/9/2024 at 4:50 p.m., with MDS Nurse 1 (MDSN 1), MDSN 1 stated CNAs should encouraged and offer resident's their own personal clothing to wear because it is their right and to be treated with dignity and respect. MDSN 1 stated CNA should have checked the closet and assist the resident to wear their clothing.
During an interview on 10/11/2024 at 2:05 p.m., the DON stated the importance of honoring resident's personal clothing to boost the dignity of the patient.
During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity, last reviewed 4/2024, the P&P indicated staff are expected to treat cognitively impaired residents with dignity and sensitivity.
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 observation, interview, and record review, the facility failed to ensure each resident received an accurate assessment,...
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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 each resident received an accurate assessment, reflective of the resident's status at the time of the assessment, for one of one sampled residents (Resident 83) investigated under the communication-sensory care area when the facility failed to accurate assess Resident 83's ability to hear in the minimum data set (MDS, a federally mandated resident assessment tool).
This deficient practice had the potential for the resident to not receive the appropriate interventions.
Cross-reference F685.
Findings:
During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 7/31/2023 with diagnoses including, but not limited to, heart disease, essential hypertension (HTN, high blood pressure), and history of falling.
During a review of Resident 83's MDS, dated [DATE], the MDS indicated Resident 83 had difficulty understanding and making decisions, required setup assistance with eating, supervision or touching assistance with oral hygiene, transferring from sit to lying, lying to sitting on the side of the bed, sit to stand, toilet transfers, walking up to 150 feet, moderate assistance with toileting hygiene and personal hygiene, and maximal assistance with showering or bathing himself, and upper and lower body dressing. The MDS further indicated Resident 83 had adequate hearing and did not use a hearing aid or hearing appliance.
During a review of Resident 83's History and Physical (H&P), dated 3/8/2024, the H&P indicated Resident 83 has the capacity to understand and make decisions.
During a review of Resident 83's Social Services Evaluation, dated 6/4/2024, the social services evaluation indicated Resident 83 had impaired hearing, did not have a hearing aid, and audio services were to be provided as needed or indicated on an emergency basis.
During a review of Resident 83's Care Plan, last revised 9/30/2024, the care plan indicated Resident 83 was at risk for communication problems related to hearing deficit. The care plan further indicated interventions included referring Resident 83 to audiology for hearing consult as ordered.
During a concurrent observation and interview with Resident 83, on 10/8/2024, at 8:46 a.m., inside Resident 83's room, Resident 83 was sitting in a wheelchair and stated he had difficulty hearing and that he wanted his ears to be cleaned so he can hear better. During the interview, Resident 83 requested to repeat the questions being asked and spoke loudly.
During an interview with Certified Nursing Assistant (CNA) 10, on 10/10/2024, at 10:14 a.m., CNA 10 stated she was assigned to Resident 83 and has provided care for the resident in the past. CNA 10 stated Resident 83 is hard of hearing and needs to speak loudly or go close to the resident to the resident for him to understand. CNA 10 further stated Resident 83 does not have a hearing aid.
During an interview with Licensed Vocational Nurse (LVN) 1, on 10/10/2024, at 10:18 a.m., LVN 1 stated she was assigned to Resident 83 and that the resident was hard of hearing. LVN 1 stated when speaking to Resident 83, she would need to repeat herself to be understood by the resident. LVN 1 stated Resident 83 does not wear or use a hearing aid and has not been seen by an audiologist. LVN 1 further stated she was not aware if Resident 83 was offered to be seen by an audiologist.
During an interview with Social Services Assistant (SSA) 1, on 10/10/2024, at 10:38 a.m., SSA 1 stated Resident 83 is hard of hearing and may need repeating for the resident to understand what is being said to him. SSA 1 stated Resident 83 does not use a hearing aid.
During a concurrent interview and record review with the Minimum Data Set Director (MDSD), on 10/11/2024, at 8:50 a.m., Resident 83's MDS, dated [DATE], was reviewed and the MDSD confirmed the assessment indicated Resident 83 did not have hearing impairment. The MDSD stated she has interacted with Resident 83 and stated the resident has impaired hearing and the MDS should have indicated the resident has impaired hearing. The MDSD further stated it is important to have an accurate assessment to accurately reflect the resident's status to have an accurate plan of care and refer the resident to the proper services.
During an interview with the Director of Nursing (DON), on 10/11/2024, at 3:28 p.m., the DON stated residents should have an accurate assessment so that the facility can provide the resident with equipment to address issues a resident may have. The DON further stated the purpose of an assessment is to see how the resident can be helped and an inaccurate assessment by the facility would fail to provide residents with the appropriate interventions.
During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, last reviewed 4/2024, the P&P indicated information in the MDS assessment will consistently reflect information in the progress notes, plans of care, and resident observations/interviews.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming and personal hygiene for two of two sampled residents (Resident 17 and 23) when:
1. The facility failed to shave Resident 17's, a female resident, facial hair.
2. The facility failed to offer and assist Resident 23 to wear their personal clothing.
These deficient practices had the potential to negatively affect the residents' psychosocial wellbeing.
Cross-reference F656.
Findings:
a. During a review of Resident 17's admission Record, the admission record indicated the facility originally admitted Resident 17 on 5/30/2023 and readmitted the resident on 6/14/2023 with diagnoses including, but not limited to, acute respiratory distress syndrome (a life-threatening lung condition that occurs when the lungs are damaged and can't provide enough oxygen to the body), hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (also known as a cerebral vascular accident or stroke, loss of blood flow to a part of the brain) affecting the left non-dominant side, and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right ankle.
During a review of Resident 17's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/20/2024, the MDS indicated Resident 17 had difficulty understanding and making decisions, had functional limitation in range of motion for one on her upper extremities and both of her lower extremities, and was dependent on facility staff for activities of daily living such as eating, personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands), toileting, showering/bathing herself, dressing, and surface-to-surface transfers.
During a review of Resident 17's History and Physical (H&P), dated 6/15/2023, the H&P indicated Resident 17 did not have the capacity to understand and make decisions.
During a review of Resident 17's Care Plan, last revised 7/10/2024, the care plan indicated Resident 17 has an activity of daily living self-care performance deficit related to, but not limited to, impaired balance, limited mobility, limited range of motion, and cerebrovascular accident. The care plan indicated interventions including, but not limited to, assistance by staff to maintain personal hygiene such as combing hair, shaving, applying makeup, washing, and drying face and hands.
During an observation on 10/8/2024, at 8:32 a.m., inside Resident 17's room, Resident 17 was sleeping in bed and had gray strands of hair above her upper lip and on her chin.
During an observation on 10/9/2024, at 9:45 a.m., inside Resident 17's room, Resident 17 was awake in bed and had gray strands of hair above her upper lip and on her chin.
During an observation on 10/9/2024, at 1:22 p.m., inside Resident 17's room, Resident 17 was awake in bed and had gray strands of hair above her upper lip and on her chin.
During a concurrent observation and interview with Certified Nursing Assistant (CNA) 10, on 10/9/2024, at 1:24 p.m., inside Resident 17's room, CNA 10 confirmed Resident 17 had facial hair above her upper lip and chin and stated the resident should not have facial hair. CNA 10 stated women should not have facial hair. CNA 10 stated female residents should be checked everyday for facial hair and should be shaved, as needed, when cleaning their face. CNA 10 further stated if female residents are not shaved, there is a potential for the resident to feel embarrassed.
During an interview with the Director of Nursing (DON), on 10/11/2024, at 3:28 p.m., the DON stated female residents should not have facial hair and should be checked every day because it is a part of the daily routine for the facility's residents. The DON further stated if female residents are not checked and shaved for facial hair, the residents can potentially feel bad and have low self-esteem.
During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, last reviewed 4/2024, the P&P indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene.
b. During a review of Resident 23's admission Record, the admission Record indicated the facility admitted the resident on 1/19/2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities).
During a review of Resident 23's MDS, dated [DATE], the MDS indicated the resident's preferences to choose what clothes to wear was very important. The MDS indicated the resident was able to make self understood and usually understood others. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with upper body dressing, lower body dressing, and putting on/taking off footwear.
During a review of Resident 23's activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) self-care performance deficit care plan, revised 2/1/2024, the care plan indicated the resident goals of not developing complications related to decreased ADL performance. The interventions included assisting the resident to choose simple comfortable clothing that enhances the resident's ability to dress self.
During an interview on 10/8/2024 at 3:22 p.m., Responsible Party 1 (RP 1) stated she has repeatedly requested the nursing staff (licensed nurses and certified nursing assistants) for Resident 23 to wear her night gown at night and not a hospital gown (a facility-provided robe worn by patients in a hospital). RP 1 stated the resident was wearing a hospital gown most of the time when she comes and visit the resident. RP 1 stated the resident has personal clothes to wear.
During a concurrent observation and interview, at Resident 23's bedside, on 10/9/2024 at 8:02 a.m., with CNA 13, CNA 13 stated she started her shift at 7:20 a.m. that day and she was the assigned CNA for Resident 23. CNA 13 stated she has not changed the resident yet. CNA 13 stated Resident 23 was wearing a hospital gown with a long-sleeve pink shirt underneath. CNA 13 stated Resident 23 wore the same clothes the previous afternoon and throughout the night.
During a concurrent observation and interview, at Resident 23's bedside, on 10/9/2024 at 4:20 p.m., with CNA 13, CNA 13 stated resident was wearing a green hospital gown. CNA 13 stated she changed Resident 23 into a new gown. CNA 13 stated Resident 23 had clothes in the closet. CNA 13 stated she would change the resident's clothes during the day shift, but because it was already after 3 p.m. she did not need to. CNA 13 stated she did not know Resident 23 had clothes in their closet. CNA 13 stated she did not check the resident's closet before putting on the hospital gown on Resident 23.
During an interview on 10/9/2024 at 4:50 p.m., with MDS Nurse 1 (MDSN 1), MDSN 1 stated CNAs should encouraged and offer resident's their own personal clothing to wear because it is their right and to be treated with dignity and respect. MDSN 1 stated CNA should have checked the closet and assist the resident to wear their clothing.
During an interview on 10/11/2024 at 2:05 p.m., the DON stated the importance of honoring resident's personal clothing to boost the dignity of the patient.
During a review of the facility's P&P titled, Activities of Daily Living, Supporting, last reviewed 4/2024, the P&P indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents receive treatment and assistive devices to maintain hearing abilities for one of one sampled resident (Resid...
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Based on observation, interview, and record review, the facility failed to ensure residents receive treatment and assistive devices to maintain hearing abilities for one of one sampled resident (Resident 83) investigated under the communication-sensory care area when the facility failed to refer Resident 83 to an otolaryngologist (ENT, also known as an ear, nose, and throat physician) and/or audiologist (physician who specializes in hearing, balance, and ear problems) for his impaired hearing.
This deficient practice resulted in a delay in care for Resident 83.
Findings:
During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 7/31/2023 with diagnoses including, but not limited to, heart disease, essential hypertension (HTN, high blood pressure), and history of falling.
During a review of Resident 83's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/6/2024, the MDS indicated Resident 83 had difficulty understanding and making decisions, required setup assistance with eating, supervision or touching assistance with oral hygiene, transferring from sit to lying, lying to sitting on the side of the bed, sit to stand, toilet transfers, walking up to 150 feet, moderate assistance with toileting hygiene and personal hygiene, and maximal assistance with showering or bathing himself, and upper and lower body dressing.
During a review of Resident 83's History and Physical (H&P), dated 3/8/2024, the H&P indicated Resident 83 has the capacity to understand and make decisions.
During a review of Resident 83's Social Services Evaluation, dated 6/4/2024, the social services evaluation indicated Resident 83 has impaired hearing, does not have a hearing aid, and audio services are to be provided as needed or indicated on an emergency basis.
During a review of Resident 83's Care Plan, last revised 9/30/2024, the care plan indicated Resident 83 was at risk for communication problems related to hearing deficit. The care plan further indicated interventions included referring Resident 83 to audiology for hearing consult as ordered.
During a concurrent observation and interview with Resident 83, on 10/8/2024, at 8:46 a.m., inside Resident 83's room, Resident 83 was sitting in a wheelchair and stated he had difficulty hearing and that he wanted his ears to be cleaned so he can hear better. During the interview, Resident 83 requested to repeat the questions being asked and spoke loudly.
During an interview with Certified Nursing Assistant (CNA) 10, on 10/10/2024, at 10:14 a.m., CNA 10 stated she was assigned to Resident 83 and has provided care for the resident in the past. CNA 10 stated Resident 83 is hard of hearing and needs to speak loudly or go close to the resident for him to understand. CNA 10 further stated Resident 83 does not have a hearing aid.
During an interview with Licensed Vocational Nurse (LVN) 1, on 10/10/2024, at 10:18 a.m., LVN 1 stated she was assigned to Resident 83 and that the resident was hard of hearing. LVN 1 stated when speaking to Resident 83, she would need to repeat herself to be understood by the resident. LVN 1 stated Resident 83 does not wear or use a hearing aid and has not been seen by an audiologist. LVN 1 further stated she was not aware if Resident 83 was offered to be seen by an audiologist.
During an interview with Social Services Assistant (SSA) 1, on 10/10/2024, at 10:38 a.m., SSA 1 stated Resident 83 is hard of hearing and may need repeating for the resident to understand what is being said to him. SSA 1 stated Resident 83 does not use a hearing aid.
During a concurrent interview and record review with the Social Services Director (SSD), on 10/10/2024, at 10:45 a.m., the facility's document titled, Appointment List ENT, dated 2/12/2024, indicated Resident 83 was not seen at that time. The SSD stated the ENT comes every six months and will refer residents to an audiologist. The SSD stated Resident 83 was not seen by the ENT and the resident would be a good candidate to be seen by the ENT.
During a concurrent interview and record review with the Minimum Data Set Director (MDSD), on 10/11/2024, at 8:50 a.m., Resident 83's Social Services Evaluation, dated 6/4/2024, was reviewed and the MDSD confirmed the evaluation indicated audio services are to be provided to the resident as needed/indicated and on an emergency basis. The MDSD stated Resident 83 has impaired hearing and should be referred to the ENT and audiologist to improve the quality of life of the resident and find the cause of the hearing impairment. The MDSD further stated if the services are not provided, the facility would not be able to meet the resident's needs.
During an interview with the Director of Nursing (DON), on 10/11/2024, at 3:28 p.m., the DON stated residents should be offered services and treatment to maintain their ability to hear every quarter, annually, or as needed. The DON stated it is important to follow up so that the facility can have an ENT evaluate the resident and check if the resident has an acute problem for hearing, check for possible infection in the ear, or wax buildup. The DON stated an audiologist can see the resident and offer a hearing aid. The DON further stated if the resident is not offered these services, the resident's concerns would not be addressed, and the appropriate interventions would not be in place to assist the resident.
During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, last reviewed 4/2024, the P&P indicated the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis.
During a review of the facility's P&P titled, Sensory Impairments - Clinical Protocol, last reviewed 4/2024, the P&P indicated as part of the initial assessment, the staff and physician will help identify individuals with sensory impairments, including hearing, taste, vision, smell, and touch. The P&P indicated the physician will order appropriate consultations to help define causes and complications of sensory impairments. The P&P indicated the staff and physician will identify approaches to help the resident improve or compensate for sensory deficits. The P&P further indicated for a resident with impaired hearing, the staff should check for cerumen, and may, as indicated, help the individual obtain a hearing evaluation, hearing aid, or employ written or other means to communicate with the individual.
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
Based on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI - localized...
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Based on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) by failing to ensure the low air loss mattress (LALM- A mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set to the correct weight for one of four sampled residents (Resident 74) investigated under the Pressure Ulcer / Injury care area.
This deficient practice had the potential to affect the redistribution capabilities (to evenly spread pressure to other areas across the body) of the LALM surface resulting in the development or worsening of pressure ulcers.
Findings:
During a review of Resident 74's admission Record, the admission Record indicated the facility admitted the resident on 9/11/2021 and most recently readmitted the resident on 5/18/2024 with diagnoses that included diseases of the liver (organ that removes toxins from the body's blood supply), displaced comminuted fracture (a bone breaks into multiple pieces) of the shaft of the right femur (thigh bone), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]).
During a review of Resident 74's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/23/2024, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS indicated the resident was dependent on staff for toileting, bathing, dressing, and required substantial assistance with rolling left and right. The MDS further indicated the resident had one Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) unhealed PI with a pressure reducing device for the bed.
During a review of Resident 74's Physician Order Summary Report, the report indicated the following order:
- Low air loss mattress, monitor placement and functionality every shift for wound management, dated 6/19/2024.
During a review of Resident 74's Care Plan (CP) titled, The resident has a stage 4 pressure injury to sacrococcyx, initiated 6/19/2024, the CP indicated an intervention of a low air loss mattress and to monitor the placement and functionality every shift for wound management.
During a review of Resident 74's Nutrition Assessment Form, dated 10/9/2024, the form indicated the resident's most recent weight was 224 pounds.
During a concurrent observation and interview on 10/8/2024 at 9:50 a.m., observed Resident 74 lying in bed on a LALM. Resident 74 stated she had a PI and is on a LALM, but it was not comfortable and if felt a little hard. Observe the LALM pump set to 320 lbs. Resident 74 stated she thinks she weighs 220 lbs.
During a concurrent observation and interview on 10/8/2024 at 9:55 a.m., observed Certified Nursing Assistant 3 (CNA 3) entered Resident 74's room. CNA 3 stated she was assigned to care for Resident 74. CNA 3 stated Resident 74 was on a LALM that was set up by the maintenance department. CNA 3 stated the LALM was set to about 330 lbs.
During a concurrent observation, interview, and record review on 10/8/2024 at 9:58 a.m., with Licensed Vocational Nurse 6 (LVN 6), LVN 6 entered Resident 74's room and stated the LALM was set to 330 lbs, but that seemed a little high. LVN 6 reviewed Resident 74's Vital's Weight form and stated that Resident 74 most recently weighed 220 lbs.
During an interview on 10/8/2024 at 10:20 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she was the treatment nurse for Resident 74. LVN 2 stated nurses should monitor LALMs to ensure the weight setting is correct and the mattress is functioning properly. LVN 2 stated the LALM should be set to the correct weight to assist healing of Resident 74's Stage 4 PI.
During an interview on 10/11/2024 at 8:58 a.m. with the Director of Nursing (DON), the DON stated the facility follows the LALM manufacture guidelines.
The DON stated the importance of the LALM is the resident benefits from the alternating air pressure of the mattress by decreasing the chance of the PI worsening for a resident with limited mobility. The DON stated the LALM is calibrated depending on the resident's weight. The DON stated when the LALM is not set to the correct weight the therapy may not be effective because the mattress is harder when it has more air. The DON stated when the surface of the mattress is too hard it may also result in the resident possibly being pushed out of the bed or sliding off the mattress.
During a review of the facility provided LALM 1 User Guide, undated, indicated to refer to the manual before use and under proper medical supervision. Improper operation of this system may cause possible injury to the user. To increase or decrease airflow for a softer or firmer mattress setting, the numbers denote suggested setting based on the patient weight.
During a review of the facility Procedure titled, Support Surface Guidelines, last reviewed 4/2024, the procedure indicated the purpose was to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Redistributing support surfaces are to promote comfort for all bed, or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Support surfaces are modifiable. Individual resident needs differ. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted the resident on 12/21/2022, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted the resident on 12/21/2022, and readmitted the resident on 7/31/2024, with diagnoses including cirrhosis of liver (a condition in which the liver is scarred and permanently damaged), encephalopathy (damage or disease that affects the brain), and viral hepatitis C (an inflammation of the liver caused by the hepatitis C virus).
During a review of Resident 66's History and Physical (H&P), dated 1/16/2023, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 66's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/9/2024, the MDS indicated the resident had the ability to make self-understood and to understand others. The MDS indicated the resident was on a high-risk drug class antibiotic.
During a review of Resident 66's Order Summary Report, dated 7/31/2024, the report indicated an order for Rifaximin tablet 550 mg. Give one tablet by mouth two times a day for hepatic encephalopathy.
During a concurrent interview and record review on 10/10/2024, at 2:14 p.m., with Registered Nurse 1 (RN 1), Resident 66's Order Summary Report, Medication Administration Record (MAR), and Physician's Progress Notes were reviewed. RN 1 stated there was an order for Rifaximin tablet 550 mg tablet without a stop date and the resident was currently taking them. RN 1 stated every time a resident will be started on an antibiotic therapy, they check the indication, the frequency of administration and how long the medication will be taken. RN 1 stated the licensed staff should have notified the physician of the lack of stop date of the antibiotic. RN 1 stated if the doctor wants the medication to be taken continuously the physician should have created a progress note indicating the risk and benefits of taking the medication for a prolonged period of time. RN 1 stated he checked the Physician's Progress Notes and did not find any indication of prolonged therapy. RN 1 stated antibiotics should have a stop date to prevent intolerance to the medication.
During a concurrent interview and record review on 10/11/2024, at 2:20 p.m., with the Director of Nursing (DON), Resident 66's Order Summary Report, MAR, and Physician's Progress Notes were reviewed. The DON stated Rifaximin tablet 550 mg is an antibiotic, and it should have a stop date to prevent antibiotic resistance on residents. The DON stated she cannot find any documentation from the physician to justify its prolonged use.
During a review of the facility's recent policy and procedure (P&P) titled Antibiotic Stewardship- Orders for Antibiotics, last reviewed on 4/2024, the P&P indicated if an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements:
a. Drug name;
b. Dose;
c. Frequency of administration;
d. Duration of treatment;
e. Start and stop date, or
f. Number of days of therapy;
g. Route of administration; and
h. Indications for use.
During a review of the facility provided Highlights of Prescribing Information for Xifaxan (rifaximin) tablets for oral use, with initial U.S. approval in 2004, the prescribing information indicated the recommended dosage of Xifaxan is one 550 mg orally three times a day for 14 days. Patients who experience a recurrence of symptoms can be retreated up to two times with the same dosage regimen.
3. During a review of Resident 390's AR, the AR indicated the facility admitted the resident on 11/27/2023, with diagnoses including adult failure to thrive (a syndrome that describes a gradual decline in an older person's physical and mental health), gastrostomy (a surgical procedure used to insert a tube, often referred to as a g-tube, through the abdomen and into the stomach), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 390's H&P, dated 11/29/2023, the H&P indicated the resident did not have the capacity to make decisions but was able to make needs known.
During a review of Resident 390's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and rarely to never had the ability to understand others. The MDS indicated the resident had a feeding tube.
During a review of Resident 390's Order Summary Report, dated 8/28/2024, the report indicated an order for:
May crush all crushable medications.
Shake well all liquids/suspension medications.
During an observation on 10/9/2024, at 8:46 a.m., during medication pass, observed Licensed Vocational Nurse 1 (LVN 1) prepare Resident 390's morning medications. Observed the following medications drawn from the medication cart and crushed crushable medications and shook liquid medications prior to pouring them in the medication cup for g tube administration, the following medications was administered via g-tube:
1. Calcium + Vitamin D3 Oral Tablet 500-5 milligram (mg, a unit of weight) - microgram (mcg, a unit of mass equal to one millionth) (Calcium Carbonate-Cholecalciferol). Give 1 tablet via G-Tube one time a day for Supplement.
Order Date 11/29/2023 6:08 p.m.
Open date of 8/3/24, expiration date of 6/2025.
2. Docusate Sodium Oral Tablet 100 mg (Docusate Sodium). Give 1 tablet via G-Tube two times a day for Bowel Management Hold if Loose Stool.
Order Date 11/29/2023 6:08 p.m.
Open date of 9/24/24, expiration date of 12/2025.
3.
Lactulose Oral Solution 10 grams (gm, unit of weight)/15 milliliters (ml, a unit of volume) (Lactulose). Give 5 ml via G-Tube one time a day for Bowel Management Hold if Loose Stool.
Order Date 11/29/2023 6:08 p.m.
Open date of 9/26/2024, expiration date of 12/2025.
4.
Haloperidol Lactate Oral Concentrate 2 mg/ml (Haloperidol Lactate). Give 1.5 ml via G-Tube two times a day for Psychosis (a group of symptoms that affect the mind and cause a person to lose touch with reality) monitor for behavior (m/b) delusional paranoia (a mental disorder in which a person has an extreme fear and distrust of others and believes that people are trying to harm them) thinking people is here to get her.
Order Date 3/14/2024 1202-D/C Date10/07/2024 6:27 p.m.
Open date of 10/5/2024, expiration date of 5/31/2025.
5.
Losartan Potassium Oral Tablet 25 mg (Losartan Potassium). Give 1 tablet via G-Tube one time a day for Hypertension Hold if systolic blood pressure (SBP) less than (<) 110.
Order Date 11/29/2023 6:08 p.m.
Expiration date of 9/12/2025.
6.
Norliqva Oral Solution 1 mg/ml (Amlodipine Besylate). Give 5 ml via G-Tube two times a day for hypertension (high blood pressure) -HOLD FOR SBP less than (<) 110.
Order Date 2/23/2024 4:43 p.m.
Open date of 9/26/2024, expiration date of 12/2026.
7.
One Daily/Minerals Oral Tablet (Multiple Vitamins w/ Minerals). Give 1 tablet via G-Tube one time a day for Supplement/Wound management.
Order Date 1/18/2024 1:37 p.m.
Open date of 10/6/2024, expiration date of 2/2026.
8.
Benztropine Mesylate Oral Tablet 0.5 MG (Benztropine Mesylate). Give 1 tablet by mouth two times a day for Tremors as evidenced by (AEB) extrapyramidal symptom (EPS, a group of side effects that affect the motor system and are caused by certain medications, especially antipsychotics).
Order Date02/22/2024 10:03 p.m.
Expiration date of 9/11/2024.
9.
Vitamin C Oral Tablet 500 MG (Ascorbic Acid). Give 1 tablet via G-Tube one time a day for Supplement/Wound management.
Order Date 1/18/2024 1:37 p.m.
Open date of 10/1/2024, expiration date of 9/2025.
During a concurrent observation and interview on 10/9/2024, at 9:14 a.m., with LVN 1, inside Resident 390's room, observed LVN 1 pour medication one at a time with in between flushes of water using a spoon to mix a couple of crushed medications mixed with water. LVN 1 stated she should not have used the same spoon on a couple of medications to stir to prevent drug interaction.
During an interview on 10/11/2024, at 3:19 p.m., with the DON, the DON stated LVN 1 should have not used the same spoon to stir a couple of crushed medication on a cup to prevent a chemical reaction of medication.
During a review of the facility's recent P&P titled, Administering Medications through an Enteral Tube, last reviewed on 4/2024, the P&P indicated the purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Administer each medication separately and flush between medications. Use a clean enteral syringe with an ENFit connector to administer medications through an enteral tube.
Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including obtaining and assuring the accurate acquisition and administering of all drug and biologicals to meet the needs for each resident for one of nine sampled residents (Resident 102) investigated under the accidents care area, one of eight sampled residents (Resident 66) investigated during initial pool sampling, and for one of three sampled residents (Resident 390) investigated during medication administration when:
1. Resident 102 had a bottle of gas relief medications, a bottle of artificial tears eye drops, and skin protectant at the bedside and stated he self-administers the medication.
This deficient practice had the potential for Resident 102 to experience adverse effects from possible reactions from taking other medications.
2. The facility failed to indicate a stop date (the date the resident is to stop taking the medication as prescribed) for the use of Rifaximin Tablet (a type of antibiotic) 550 milligrams (mg, a unit of weight), for Resident 66 being investigated during initial sampling of residents.
This deficient practice had the potential to result in unnecessarily prolonged therapy increasing the risk of antimicrobial resistance (resistance to bacteria, viruses, fungi, and parasites), super-infection (reinfection or a second infection with a microbial agent), and adverse events (a harmful or abnormal result).
3. The facility failed to use a different spoon to mix a couple of medications placed on medication cups with crushed medications for Resident 390 observed during medication administration facility task.
This deficient practice could potentially lead to dangerous drug interactions, alter their effectiveness, and make it difficult to accurately dose each medication due to potential chemical reactions between the different drug compounds.
Cross-reference F656 and F689.
Findings:
1. During a review of Resident 102's admission Record, the admission record indicated the facility originally admitted Resident 102 on 2/21/2024 with diagnoses including, but not limited to, type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (high blood pressure).
During a review of Resident 102's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/27/2024, the MDS indicated Resident 102 was able to understand and make decisions, required setup assistance with eating, and required moderate to maximal assistance or was dependent on staff for activities of daily living such as hygiene, showering/bathing himself, dressing, toileting, and surface-to-surface transfers.
During a review of Resident 102's History and Physical (H&P), dated 2/21/2024, the H&P indicated Resident 102 had the capacity to understand and make his own medical decisions.
During a review of Resident 102's Self Administration of Medication, dated 8/27/2024, the self-administration of medication indicated Resident 102 was not granted approval to self-administer.
During a review of Resident 102's Order Summary Report, current as of 10/9/2024, the order summary report did not indicate an order for gas relief medication, artificial tears eye drops, or skin protectant.
During a review of Resident 102's Care Plans, current as of 10/9/2024, the care plans did not indicate the resident can self-administer medications or keep medications at the bedside.
During an observation on 10/8/2024, at 9:05 a.m., inside Resident 102's room, Resident 102 was sleeping in bed with the bedside table positioned to the right of the resident. The bedside table had a bottle of gas relief medication and a tube of skin protectant.
During a concurrent observation and interview with Resident 102, on 10/8/2024, at 12:26 p.m., inside Resident 102's room, a bottle of gas relief medication and a bottle of artificial tears eye drops were on top of Resident 102's bedside table and a tube of skin protectant was below the television placed on a dresser to the left of the resident. Resident 102 confirmed he had the medications at the bedside and stated he was allowed to keep his medications at the bedside.
During an observation on 10/20/2024, at 1:34 p.m., inside Resident 102's room, a bottle of gas relief medication and a bottle of artificial tears eye drops were on a table placed to the right of the resident.
During a concurrent interview and record review with the Minimum Data Set Director (MDSD), on 10/11/2024, at 9:25 a.m., Resident 102's Order Summary Report, current as of 10/11/2024, was reviewed and the MDSD confirmed Resident 102 did not have an order for gas relief medication, artificial tears, and skin protectant. The MDSD stated Resident 102 should have an order for use of those medications so that the physician can approve the use of the medications.
During a concurrent observation and interview with the MDSD, on 10/11/2024, at 9:34 a.m., inside Resident 102's room, the MDSD confirmed Resident 102 had a bottle of gas relief medication, a bottle of artificial tears eye drops, and three tubes of skin protectant at the bedside. The MDSD stated Resident 102 should have an order for those medications to make sure the resident is prescribed the correct medication. The MDSD further stated there is a potential for Resident 102 to experience adverse effects and/or there can be a potential reaction with other medications the resident is taking.
During an interview with the Director of Nursing (DON), on 10/11/2024, at 3:28 p.m., the DON stated there should be a physician's order for medications a resident is taking. The DON stated the physician needs to approve the use of medications. The DON stated if the resident experiences an adverse reaction from use of medication, the facility would not be able to identify the cause. The DON further stated if a physician's order is not obtained, there is a potential for harm from incompatibility between medications.
During a review of the facility's policy and procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed 4/2024, the P&P indicated examples of medication errors include unauthorized drugs, a drug administered without a physician's order.
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 the entire medication regimen of the resident was managed an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the entire medication regimen of the resident was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for two of five sampled residents (385 and 65) investigated under unnecessary medications review by failing to:
1. Obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Resident 385's use of psychotropic medication (Donepezil, used to treat dementia [memory loss and mental changes] associated with mild, moderate, or severe Alzheimer's disease [a disease characterized by a progressive decline in mental abilities]).
2. Monitor for adverse effects (a harmful or abnormal result) of Resident 65's use of antidepressant (Duloxetine, a medication used to treat major depressive disorder [a serious mental illness that can affect how a person feels, thinks, and acts).
These deficient practices violated the residents right to informed consent and had the potential to result in the use of unnecessary psychotropic drugs and adverse effects (an undesired and harmful result of a treatment or intervention, such as a medication or surgery) of the medication.
Findings:
1. During a review of Resident 385's admission Record (AR), the AR indicated the facility admitted the resident on 10/3/2024, with diagnoses including dementia (a progressive state of decline in mental abilities) and depression.
During a review of Resident 385's Order Summary Report, dated 10/3/2024, the report indicated an order for Donepezil HCl Oral Tablet 5 mg (Donepezil Hydrochloride). Give 1 tablet by mouth one time a day for dementia.
During a review of Resident 385's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/9/2024, the MDS indicated the resident had intact cognition (the ability to maintain a relatively high level of mental functioning, including thinking, learning, memory, and perception).
During a review of Resident 385's History and Physical (H&P), dated 10/11/2024, the H&P indicated the resident had the ability to understand and to make decisions.
During a concurrent interview and record review, on 10/10/2024, at 9:54 a.m., with Registered Nurse 1 (RN 1), Resident 385's Order Summary Report and Consents were reviewed. RN 1 stated Resident 385 had an order for donepezil HCl Oral 5 mg tablets and there was no consent for its use. RN 1 stated it is important to explain the risk and benefits on the use of psychotropic medications and obtain a consent to the resident or resident representative to honor their right to informed consent.
During an interview on 10/11/2024, at 2:09 p.m., with the Director of Nursing (DON), the DON stated before starting a psychotropic drug regimen on a resident the staff should explain the risk and benefits of taking the drug and obtain a consent from the resident or representative to honor the resident's right to informed consent.
During a review of the facility's most recent policy and procedure (P&P) titled Health, Medical Condition and Treatment Options, Informing Residents of, last reviewed on 4/2024, the P&P indicated every resident is informed of his or her total health status, medical condition, and options for treatment. Each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance treatment and an on-going basis. If a resident has an appointed representative, the representative is also informed.
During a review of the facility's recent policy and procedure (P&P) titled Psychotropic Medication Use, last reviewed on 4/2024, the P&P indicated psychotropic medication management includes:
d. Adequate monitoring for efficacy and adverse consequences; and
e. Preventing, identifying, and responding to adverse consequences.
Residents (and/or representatives) have the right to decline treatment with psychotropic medications.
a. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.
2.
During a review of Resident 65's admission Record (AR), the AR indicated the facility admitted the resident on 5/28/2024, and readmitted the resident on 8/5/2024, with diagnoses including anxiety disorder (a condition where a person has excessive and persistent feelings of fear, dread, and uneasiness) and major depressive disorder.
During a review of Resident 65's Care Plan (CP) titled The resident uses antidepressant medication (duloxetine) related to depression ., last revised on 5/28/2024, the CP indicated an intervention to monitor/document/report if needed (PRN) adverse reactions to antidepressant therapy.
During a review of Resident 65's H&P, dated 6/4/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 65's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug of antianxiety and antidepressant medications.
During a review of Resident 65's Order Summary Report, dated 9/9/2024, the report indicated an order for duloxetine hcl oral capsule delayed release particles 30 mg (Duloxetine HCl). Give one capsule by mouth two times a day for major depressive disorder. Monitor for behavior (m/b) sad facial expression. The report did not indicate any monitoring for adverse effect for the use of antidepressant (duloxetine).
During a review of Resident 65's Medication Administration Record (MAR) for 10/2024, the MAR did not indicate any monitoring for adverse effect of the medication (duloxetine).
During a concurrent interview and record review on 10/10/2024, at 11:10 a.m., with RN 1, Resident 65's Order Summary Report, MAR, and CP were reviewed. RN 1 stated there was an order for duloxetine HCl oral 30 mg capsule delayed release particles, however, there was no order for monitoring for its adverse effect. RN 1 stated it is important to monitor for adverse effects on the use of duloxetine to ensure the adverse effects were timely reported to the attending physician to mitigate its effect.
During a concurrent interview and record review on 10/11/2024, at 2:11 p.m., with the DON, Resident 65's order summary report and MAR. The DON stated there was an order for duloxetine hcl capsule but there was no order for monitoring its side effects. The DON stated it is important to monitor for the adverse effect/side effect of the medication to establish a basis for the physician to continue or discontinue the medication.
During a review of the facility's most recent policy and procedure (P&P) titled Psychotropic Medication Use, last reviewed on 4/2024, the P&P indicated psychotropic medication management includes:
d. Adequate monitoring for efficacy and adverse consequences; and
e. Preventing, identifying, and responding to adverse consequences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain medical records with accepted professional standards to one of five sampled residents (Residents 57) selected for immunization rev...
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Based on interview and record review, the facility failed to maintain medical records with accepted professional standards to one of five sampled residents (Residents 57) selected for immunization review by failing to ensure to document vaccine (medications used to prevent diseases usually given by injection or by mouth) administration on the Medication Administration Record (MAR) when influenza vaccine (flu shot) and coronavirus disease-2019 (COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms) vaccine they were administered.
This deficient practice had the potential to result in inaccurate documentation in the medical record regarding Residents 57's immunization record.
Findings:
During a review of Resident 57's admission Record, the admission Record indicated the facility originally admitted the resident on 4/28/2021 and readmitted the resident on 9/12/2024 with diagnoses including orthopedic (relating to musculoskeletal system encompassing muscles, bones, tendons, ligaments, and joints) aftercare following surgical amputation (removal of all or part of a limb or an extremity) and type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control) with hyperglycemia (high blood sugar).
During a review of Resident 57's Skilled Nursing History and Physical (H&P), dated 9/18/2024, the H&P indicated the resident has the capacity to understand and make decisions.
During a review of Resident 57's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/16/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The resident had intact cognition (mental process that take place in the brain, including thinking, attention, language, learning, memory, and perception).
During a review of Resident 57's MAR for the month of 9/2024,t he MAR indicated the following:
-
May administer annual influenza vaccination one time only until 9/27/2024, order date 9/27/2024.
-
May administer COVID-19 2024-2025 vaccination one time only until 9/27/2024, order date 9/27/2024.
During a concurrent interview and record review of Resident 57's MAR for the month of 9/2024, on 10/10/2024 at 2:24 p.m., with MDS Nurse 1 (MDSN 1), MDSN 1 stated the resident's annual influenza and COVID-19 vaccine had no initial of the licensed nurse who administered the vaccines on 9/27/2024. MDSN 1 stated the Infection Preventionist (IP) is the one who facilitated the immunization and should have signed the resident's MAR once completed.
During an interview on 10/11/2024 at 2:00 p.m., the Director of Nursing (DON) stated they had an outside clinic come and visit (administered the influenza and COVID-19 vaccinations) to the residents. The DON stated the IP is responsible for documenting on the monitoring for 72 hours and the administration site. The DON stated documenting in the MAR to make sure vaccine was administered and avoid duplication of administration. The DON stated the potential on not documenting on the MAR places the resident at risk for breakdown of communication with the licensed nurses if it was administered or not.
During a review of the facility's recent policy and procedure (P&P) titled Charting and Documentation, last reviewed on 4/2024, the P&P indicated the following information is to be documented in the resident medical record including medications administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 10/8/2024 at 9:10 a.m., the Hoyer lift not was not plugged in the wall outlet near Station A.
During...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 10/8/2024 at 9:10 a.m., the Hoyer lift not was not plugged in the wall outlet near Station A.
During a concurrent observation and interview on 10/9/2024, at 8:05 a.m., with Certified Nursing Assistant 5 (CNA 5), at the hallway near Station A the Hoyer lift still was not plugged in the wall outlet. CNA 5 stated the Hoyer lift should be plugged in the wall outlet to charge the battery when not in use, to prevent the Hoyer lift from draining its battery while a resident is suspended on a Hoyer lift sling that can potentially cause an accident.
During an interview on 10/11/2024, at 2:09 p.m., with the Director of Nursing (DON), the DON stated Hoyer lift should be plugged in the wall outlet to charge the battery when not in use to avoid interruption while using the machine.
During a review of the facility's recent policy and procedure (P&P) titled Lifting Machine, Using a Mechanical, last reviewed on 4/2024, the P&P indicated to make sure the battery is charged.
During a review of the facility's recent policy and procedure (P&P) titled Safe Lifting and Movement of Residents, last reviewed on 4/2024, the P&P indicated mechanical lifts shall be made readily available to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being charged.
During a review of the facility provided undated Patient Lift 1 (PL 1) User Manual, the manual indicated it is recommended that the battery should be recharged daily to prolong battery life.
Based on observation, interview, and record review the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition investigated during random observations by:
1. Failing to ensure the bed controller (device used to change the height and angle of the bed) cords for Resident 114 and Resident 22 did not have exposed wires.
2. Failing to ensure the call light (a device used by a resident to signal his or her need for assistance from staff) cord for Resident 104 did not have exposed wires.
These deficient practices had the potential to place the residents at risk for injury.
3. Failing to ensure the Hoyer lift (a medical device that helps caregivers move patients from one place to another with minimal physical effort) was plugged in the wall outlet to charge when not in use.
The deficient practice had the potential to result in the Hoyer lift to stop working while the resident was suspended in the Hoyer lift sling (a harness that attaches to a Hoyer lift to help move patients who have limited mobility or are bed-bound) that can lead to accidents.
Findings:
1.1. During a review of Resident 114's admission Record, the admission Record indicated the facility admitted the resident on 3/1/2024 with diagnoses including to altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting the brain), atrial fibrillation (a condition where the heart's upper chambers beat irregularly and often too fast, causing the heart to not pump blood properly), and facial weakness following cerebral infarction (a type of stroke that occurs when a blood clot blocks blood flow to the brain).
During a review of Resident 114's History and Physical (H&P) dated 3/2/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 114's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/22/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required set-up or clean-up assistance with eating; supervision/touching assistance with rolling from left and right; substantial/maximal assistance with toileting hygiene and showering/bathing self; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During an observation on 10/8/2024 at 10:32 a.m., inside Resident 114's room with Certified Nursing Assistant 2 (CNA 2), observed the base of Resident 114's bed controller with the white, gray, blue, yellow, red, and green wires exposed.
During an interview on 10/8/2024 at 11:00 a.m. with the Maintenance Supervisor (MS), the MS stated that he was awaiting delivery of bed controllers that were ordered. The MS stated there is a possibility Resident 114 can get electrocuted with the exposed wires from the bed controller which can result to getting injuries.
During an interview on 10/8/2024 at 11:15 a.m., with the Director of Nursing (DON, the DON stated Resident 22's bed control cord was wrapped with white plastic tape and had the white, gray, blue, yellow, red, and green wires exposed (not covered with the tape). The DON stated the maintenance department oversees maintaining resident care equipment in good working condition. The DON stated the MS should have replaced the bed control immediately as it can place the resident at risk for injuries from possible electrocution.
During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, last reviewed 4/2024, the P&P indicated:
The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
Functions of maintenance personnel include but not limited to maintaining the building in good repair and free of hazards.
During a review of the facility's P&P titled, Hazardous Areas, Devices, and Equipment, last reviewed 4/2024, the P&P indicated all hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. The P&P indicated a hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to devices and equipment that are improperly used or poorly maintained.
1.2. During a review of Resident 22's admission Record, the admission Record indicated the facility admitted the resident on 5/31/2017 and readmitted the resident on 9/16/2018 with diagnoses including type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high) generalized muscle weakness, and osteoarthritis (a chronic condition where the joints in your body become inflamed and damaged, causing pain, swelling, stiffness and reduced movement).
During a review of Resident 22's H&P dated 5/20/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 22's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognition and required set up or clean up assistance with eating; supervision/touching assistance with rolling left and right; partial/moderate assistance from staff with all other ADLs.
During an observation on 10/8/2024 at 10:23 a.m., inside Resident 22's room, observed the base of Resident 22's bed control wrapped with white colored plastic tape. Further down the bed controller cable, observed white, gray, blue, yellow, red, and green wires exposed and not covered with the tape.
During a concurrent observation and interview on 10/8/2024 at 10:39 a.m. inside Resident 22's room with CNA 2, CNA 2 stated Resident 22's bed controller was covered with white tape but the white, gray, blue, yellow, red, and green wires were exposed. CNA 2 stated the exposed wires can get Resident 22 electrocuted which may lead to injuries.
During an interview on 10/8/2024 at 11:00 a.m. with the Maintenance Supervisor (MS), the MS stated that he was awaiting delivery of bed controllers that were ordered. The MS stated he is aware of the issue. The MS stated there is a possibility Resident 22 can get electrocuted with the exposed wires from the bed controller which can result to getting injuries.
During an interview on 10/8/2024 at 11:15 a.m., with the Director of Nursing (DON, the DON stated Resident 22's bed control cord was wrapped with white plastic tape and had the white, gray, blue, yellow, red, and green wires exposed (not covered with the tape). The DON stated the maintenance department oversees maintaining resident care equipment in good working condition. The DON stated the MS should have replaced the bed control immediately as it can place the resident at risk for injuries from possible electrocution.
During a review of the facility's P&P titled, Maintenance Service, last reviewed 4/2024, the P&P indicated:
The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
Functions of maintenance personnel include but not limited to maintaining the building in good repair and free of hazards.
During a review of the facility's P&P titled, Hazardous Areas, Devices, and Equipment, last reviewed 4/2024, the P&P indicated all hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. The P&P indicated a hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to devices and equipment that are improperly used or poorly maintained.
1.3 During a review of Resident 104's admission Record, the admission Record indicated the facility admitted the resident on 10/1/2023 with diagnoses including DM 2, history of falling, and dependence on supplemental oxygen.
During a review of Resident 104's H&P dated 10/4/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 104's MDS dated [DATE], the MDS indicated the resident had an intact cognition) and required set-up or clean-up assistance with eating; supervision/touching assistance with rolling left and right; partial/moderate assistance from staff with all other ADLs.
During an observation on 10/8/2024 at 11:58 a.m., inside Resident 104's room with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated Resident 104's call light on top of the bed had wires exposed at the base of the call light. LVN 5 stated the wires exposed were black and white. LVN 5 stated the resident can get injuries from accidents like electrocution.
During an interview on 10/8/2024 at 11:15 a.m., with the Director of Nursing (DON, the DON stated the maintenance department oversees maintaining resident care equipment in good working condition.
During a review of the facility's P&P titled, Maintenance Service, last reviewed 4/2024, the P&P indicated:
The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
Functions of maintenance personnel include but not limited to maintaining the building in good repair and free of hazards.
During a review of the facility's P&P titled, Hazardous Areas, Devices, and Equipment, last reviewed 4/2024, the P&P indicated all hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. The P&P indicated a hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to devices and equipment that are improperly used or poorly maintained.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of his or her qual...
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Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life and by failing to:
1. Ensure Licensed Vocational Nurse 6 (LVN 6) knocked before entering the resident's room, requested permission to enter the resident's room, and did not loudly state the resident's name in a decibel heard 35 feet (a unit of measurement) away at Station A for one of three sampled residents (Resident 68) reviewed during the Dignity care area.
2. Ensure LVN 6 treated Resident 68, and an additional two of seven resident's present during the Resident Council task, with professionalism for one of three sampled residents (Resident 68) reviewed during the Dignity care area and two of seven additional residents interviewed during the Resident Council task.
3. Maintain resident privacy while undressing the resident for one of three sampled residents (Resident 83) investigated under the dignity care area.
These deficient practices violated resident's rights to privacy and to be treated with respect and dignity; and had the potential to result in a decrease in psychosocial well-being and a decrease in the quality of life for residents.
[cross-reference to F656]
Findings:
1.During a review of Resident 68's admission Record, the admission Record indicated the facility admitted the resident on 9/2/2020 and readmitted the resident on 11/15/2023 with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified systolic heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), and hypertension (HTN-high blood pressure).
During a review of Resident 68's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/30/2024, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required partial/moderate assistance from staff for bathing and dressing, required supervision for toileting and personal hygiene and required setup or clean up assistance for eating and oral hygiene.
During a review of Resident 68's Self-Administration of Medication form, dated 9/6/2024, the form indicated self-administration is not granted and the licensed nurse will administer resident's medication as ordered.
During a concurrent observation and interview on 10/8/2024 at 10:45 a.m., observed Resident 68 lying in bed with his eyes closed. Observed a plastic medication cup containing eight medications on the bedside rolling table. Resident 68 opened his eyes and stated the medications were his and the nurse left them there for him to take, but he fell back asleep.
During an interview on 10/8/2024 at 10:54 a.m., with Licensed Vocational Nurse 6 (LVN 6) in Station A, LVN 6 stated she left Resident 68's medications at bedside with him to administer himself. Observed LVN 6 walk to Resident 68's room, entered the room without knocking or requesting permission to enter, and loudly stated Resident 68's first name in a decibel heard at Station A. The surveyor then walked toward Resident 68's room and observed Resident 68 stated that he fell asleep and forgot to take the medications. LVN 6 exited the resident's room and returned to Station A. LVN 6 stated she knows she is not supposed to leave medications at bedside, but Resident 68 is cranky and she just left them there.
During a follow up interview on 10/8/2024 at 11:05 a.m., LVN 6 stated she did not knock or introduce herself prior to entering Resident 68's room because the resident was sleeping, and she needed to see why he didn't take his medications.
LVN 6 stated she knows she should knock before entering when residents are sleeping, but she didn't. LVN 6 stated she is supposed to knock and introduce herself before entering a resident's room for the resident's right to privacy.
During a Resident Council interview on 10/9/2024 at 2 p.m., Resident 68, and two of seven other residents present during the interview, stated LVN 6 does not act professionally towards them.
During a follow up interview on 10/10/2024 at 12 p.m., with Resident 68, Resident 68 and stated on 10/8/2024 when LVN 6 entered his room and loudly stated his name, LVN 6 then stated that Resident 68 got her in trouble when he fell asleep and did not take his medication. Resident 68 stated LVN 6 got herself in trouble. Resident 68 stated LVN 6's actions on 10/8/2024 made him feel not very good at all.
During a concurrent observation and interview on 10/11/2024 at 7:59 a.m., the Maintenance Supervisor (MS) measured the distance from Resident 68's room to Station A. The MS stated Resident 68's room entrance is 35 feet from Station A.
During an interview on 10/11/2024 at 8:58 a.m., with the Director of Nursing (DON), the DON stated LVN 6 has a certain tone to her voice. The DON stated when the DON asked LVN 6 about leaving medications at Resident 68's bedside and not knocking prior to entering the resident's room, LVN 6 responded with just a smile. The DON stated resident 68's room is not close to Station A and 35 feet is a long way to hear a nurse's voice speaking to a resident. The DON stated residents have the right to be treated with dignity and respect. The DON stated when residents are not treated with dignity and respect it can have a negative psychosocial impact on them. The DON stated the facility policy was not followed when LVN 6 did not act professionally towards residents and did not knock and introduce herself when she entered Resident 68's room and loudly stated his name.
During a review of the facility policy and procedure titled, Resident Rights, last reviewed 4/2024, the policy indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:
-a dignified existence
-be treated with respect, kindness, and dignity
-be supported by the facility in exercising his or her rights
-privacy and confidentiality
During a review of the facility policy and procedure titled, Quality of Life - Dignity, last reviewed 4/2024, the policy indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Residents are treated with dignity and respect at all times. The facility culture is one that supports and encourages humanization and individualization of residents, and honors resident choices, preferences, values and beliefs. Residents' private space and property are respected at all times. Staff are expected to knock and request permission before entering residents' rooms. Staff speak respectfully to residents at all times. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Demeaning practices and standards of care that compromise dignity are prohibited.
3. During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 7/31/2024 with diagnoses including, but not limited to, heart disease, essential hypertension (HTN, high blood pressure), and history of falling.
During a review of Resident 83's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/6/2024, the MDS indicated Resident 83 had difficulty understanding and making decisions, required setup assistance with eating, supervision or touching assistance with oral hygiene, transferring from sit to lying, lying to sitting on the side of the bed, sit to stand, toilet transfers, walking up to 150 feet, moderate assistance with toileting hygiene and personal hygiene, and maximal assistance with showering or bathing himself, and upper and lower body dressing.
During a review of Resident 83's History and Physical (H&P), dated 3/8/2024, the H&P indicated Resident 83 has the capacity to understand and make decisions.
During an observation on 10/8/2024, at 8:49 a.m., from the hallway outside of Resident 83's room, Certified Nursing Assistant (CNA) 8 placed Resident 83 in a shower chair located between the foot of the bed and the resident bathroom. CNA 8 undressed Resident 83 while in the shower chair and Resident 83 was visible from the hallway.
During an interview with CNA 8, on 10/8/2024, at 8:54 a.m., CNA 8 confirmed Resident 83 was undressed inside his room and was visible from the hallway. CNA 8 stated Resident 83 should have been undressed from behind his privacy curtain. CNA 8 further stated if the resident is visible while undressing, it can affect the resident's privacy and can make the resident feel disrespected.
During an interview with the Director of Nursing (DON), on 10/11/2024, at 3:28 p.m., the DON stated residents should be provided bodily privacy while undressing by closing the curtains or door. The DON stated further stated if residents are not provided privacy, the residents could potentially feel violated and embarrassed.
During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity, last reviewed 4/2024, the P&P indicated staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedure.
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** 3. During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted the resident on 12/21/2022, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted the resident on 12/21/2022, and readmitted the resident on 7/31/2024, with diagnoses including displaced fracture of the right femur (a break in the thigh bone where the bone fragments are not aligned), abnormalities of gait (manner of moving on foot) and mobility, and history of falling.
During a review of Resident 66's History and Physical (H&P), dated 1/16/2023, the H&P indicated the resident had the capacity to understand and to make decisions.
During a review of Resident 66's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, the MDS indicated the resident has the ability to make self-understood and to understand others. The MDS indicated the resident had severe cognitive impairment (a condition where a person has difficulty with basic tasks and is unable to live independently) and was dependent to requiring substantial to maximal assistance on mobility and activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During an observation on 10/8/2024, at 8:56 a.m., during resident screening, Resident 66 was observed lying in bed with the bed placed against the wall at the right side of the bed.
During a concurrent observation, interview, and record review, on 10/10/2024, at 9:34 a.m., with Registered Nurse 1 (RN 1), while inside Resident 66's room, Resident 66's Order Summary Report, Assessment for safety on the use of the restraint bed placed against the wall, Consents, and Care Plans were reviewed. RN 1 stated there was no physician's order, no physical restraint assessment, no consent from the resident/representative, and no care plan on the use of a restraint bed placed against the wall. RN 1 stated it is important to ensure all the above steps were done prior to the application of the restraint for its safe use and to honor the resident's right to informed consent.
During an interview on 10/11/2024, at 2:08 p.m., with the Director of Nursing (DON), the DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident or the resident representative prior to placing the resident's bed against the wall to ensure resident safety and to honor the resident's right to accept or refuse the treatment.
During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed on 4/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted including:
a. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed;
d. Placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising. Prior to placing a resident in restraints, shall be a pre-restraining assessment and review to determine the need for restraints.
Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (Sponsor). The order shall include the following:
a. The specific reason for the restraint (as it relates to the resident's medical symptom);
b. How the restraint will be used to benefit the resident's medical symptom; and
c. The type of restraints, and period of time for the use of the restraint.
Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraints reduction, less restrictive methods of restraints, or total restraint elimination. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s).
During a review of the facility's recent policy and procedure (P&P) titled Health, Medical Condition and Treatment Options, Informing Residents of, last reviewed on 4/2024, the P&P indicated every resident is informed of his or her total health status, medical condition, and options for treatment. Each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance treatment and an on-going basis. If a resident has an appointed representative, the representative is also informed.
Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for three (3) out of three (3) sampled residents (Residents 75 and 116) investigated during a review of physical restraints care area by:
1. Failing to complete a restraint assessment prior to use of a sensor pad alarm (a device that triggers an audible alarm when a patient attempts to rise off the pad) for Resident 75.
2. Failing to obtain a physician's order, informed consent, complete a restraint assessment, and develop and implement a care plan on the use of bed placed against the wall for Resident 116 and 66.
These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from), and death of residents.
Findings:
1. During a review of Resident 75's admission Record, the admission Record indicated the facility admitted the resident on 9/18/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high) generalized muscle weakness, and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
During a review of Resident 75's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/24/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up or clean up assistance with personal hygiene, supervision/touching assistance with eating, oral hygiene, roll left and right, sit to lying, lying to sitting on edge of bed, substantial/maximal assistance with toileting hygiene, and shower/bathing self, and partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 75 did not have impairment of both upper and lower extremities.
During a review of Resident 75's History and Physical (H&P) dated 9/27/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 75's Order Summary Report, the Order Summary Report indicated a physician's order dated 9/30/2024 to apply sensor pad alarm in the resident's bed to remind the resident to call for assistance and alert staff when moving or getting up from bed every shift. And to monitor for presence, placement, and functionality every shift for fall prevention.
During a review of Resident 75's care plan for an actual fall incident when resident was found sitting on the floor initiated 9/30/2024, last revised 10/1/2024, the care plan indicated to apply a sensor pad alarm in the bed as one of the interventions to prevent injuries and fall incidents.
During a review of Resident 75's fall risk assessments dated 9/18/2024, 9/23/2024, and 9/30/2024, the fall risk assessments indicated the resident was a high risk for falls.
During a concurrent observation and interview on 10/9/2024 at 2:15 p.m. inside Resident 75's room with Certified Nursing Assistant 9 (CNA 9), Resident 75 was observed lying in bed with the sensor pad alarm positioned on the left upper half side rail and secured with a hook. CNA 6 verified the sensor pad alarm switch was turned off. CNA 6 stated she did not know who turned off the alarm. CNA 6 stated the sensor pad alarm was to help prevent the resident from getting up unassisted and fall. CNA 6 stated the alarm should not have been turned off. CNA 6 stated if the alarm was turned off, the staff would be unable to know if the resident got out of bed unassisted and can fall and lead to injury.
During a concurrent interview and record review of 10/11/2024 at 12:10 p.m., Resident 75's physician's orders, fall risk assessments, informed consents, and care plans with [NAME] Data Set Nurse 1 (MDSN 1) were reviewed. MDSN 1 stated the facility considered the sensor pad alarm as a nursing intervention not a restraint, hence, there was no device use evaluation or assessment completed prior to use. MDSN 1 stated the sensor pad alarm was used to prevent the resident from getting up unassisted by alerting the staff and reminding the resident to call for assistance. MDSN 1 stated a restraint assessment should have been completed prior to use to ensure appropriateness of the intervention.
During an interview on 10/11/2024 at 3:30 p.m., the Director of Nursing (DON) stated the sensor pad alarm was used on the resident to alert staff when Resident 75 gets out of bed unassisted and to remind the resident to ask for assistance prior to getting up without assistance. The DON stated the sensor pad alarm was considered a restraint as it restricts the resident to move freely in the bed without hearing the alarm, therefore, there should have been a restraint use assessment to ensure the appropriateness of the use of alarm.
During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, last reviewed 4/2024, indicated:
-Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.
-The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint.
-Prior to placing a resident on restraints, there shall be a pre-restraining assessment and review to determine the need for restraints.
During a review of the facility's P&P titled, Tab Alarms, Bed Alarms, Wanderguard System, last reviewed 4/2024, indicated:
-Tab alarms or bed alarms may be used on a resident who is deemed unsafe through the nursing assessment.
-After each application of the tab alarm(s), bed alarm(s), or wanderguard bracelet in place, a licensed nursing staff/appropriate designee will conduct a safety check to verify alarm device used is in proper working condition including proper function and placement to facility used alarm system per manufacturer instruction before leaving the resident.
2. During a review of Resident 116's admission Record, the admission Record indicated the facility admitted the resident on 5/31/2024 and readmitted the resident 7/31/2024 with diagnoses including but not limited to history of falling, malignant neoplasm of breast (abnormal growth of tissue in the breast capable of spreading to other parts of the body), and psychosis (a condition that affects the brain and causes the individual to believe and experience things that are not real).
During a review of Resident 116's History and Physical (H&P) dated 8/6/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 116's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/9/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up or clean up assistance with eating; supervision/touching assistance with roll left and right, sit to lying , lying to sitting on edge of bed, sit to stand, and ambulating up to 150 feet; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 116 did not have impairment of both upper and lower extremities.
During a review of Resident 116's Order Summary Report, the Order Summary Report did not indicate a physician's order to place the bed against the wall.
During a review of Resident 116's care plan on risk for falls related to confusion, gait or balance problems, history of multiple falls, and multiple contributing medical condition or diagnoses initiated 5/31/2024 and last revised 10/9/2024, did not indicate bed placed against the wall as on the of the interventions.
During a review of Resident 116's fall risk assessments dated 7/31/2024, 8/14/2024, 9/27/2024, and 10/7/2024, the fall risk assessments indicated the resident was a high risk for falls.
During a concurrent observation and interview on 10/8/2024 at 11:42 a.m., inside Resident 116's room with Certified Nursing Assistant 7 (CNA 7), CNA 7 verified Resident 116's bed was placed against the wall on the right side. CNA 7 stated the bed against the wall was to prevent the resident from getting out of bed from the left side as the resident had a history of falls.
During a concurrent observation and interview on 10/8/2024 at 11:49 a.m., inside Resident 116's room with Licensed Vocational Nurse 4 (LVN 4), LVN 4 verified Resident 116's bed was placed against the wall on the right side. LVN 4 stated the bed was placed against the wall on the right side because Resident 116 had multiple fall incidents and to prevent any injuries in case the resident falls on the right side from getting up unassisted.
During a concurrent interview and record review on 10/11/2024 at 11;14 a.m., Resident 116's physician's order, care plan, informed consents, and restraint assessment were reviewed with Minimum Data Set Nurse 1 (MDSN 1). MDSN 1 stated she identified Resident 116's bed was placed against the wall, and it was considered a restraint as it restricts the resident from getting out of bed from the right side. MDSN 1 verified Resident 116 did not have impairment on both upper and lower extremities. MDSN 1 stated a physical restraint assessment should have been completed, obtain an informed consent from the resident or resident representative, obtain an order from the physician, and develop and implement a care plan prior to placing the bed against the wall as a restraint.
During a concurrent interview and interview on 10/11/2024 at 3:35 p.m. reviewed the facility's policy and procedure (P&P) titled, Use of Restraints with the Director of Nursing (DON), the DON verified placing the bed against the wall was considered a restraint as it restricts the resident's movement from the other side of the bed. The DON stated a physical restraint assessment should have been completed to ensure necessity of the restraint, obtain an informed consent from the resident or resident representative to be aware of the risks and benefits of the restraint, obtain an order from the physician, and develop and implement a care plan prior to placing the bed against the wall as a restraint.
During a review of the facility's P&P titled, Use of Restraints, last reviewed 4/2024, the P&P indicated the following:
-Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.
-Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.
-The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint.
-Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted including:
a. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed;
d. Placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising. Prior to placing a resident in restraints, shall be a pre-restraining assessment and review to determine the need for restraints.
-Prior to placing a resident on restraints, there shall be a pre-restraining assessment and review to determine the need for restraints.
-Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (Sponsor). The order shall include the following:
a. The specific reason for the restraint (as it relates to the resident's medical symptom);
b. How the restraint will be used to benefit the resident's medical symptom; and
c. The type of restraints, and period of time for the use of the restraint.
-Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use.
-Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to develop and implement a baseline care plan for one of eight sampled residents (Resident 385) during initial sampling by failing to develop ...
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Based on interview and record review, the facility failed to develop and implement a baseline care plan for one of eight sampled residents (Resident 385) during initial sampling by failing to develop and implement a care plan for the use of oxygen therapy (a t]treatment in which a storage tank of oxygen or a machine called a compressor is used to give oxygen to people with breathing problems), psychotropic medications (Donepezil, Mirtazapine, Trazadone [are drugs or substances that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior]), and anticoagulant (warfarin, an anticoagulant drug used to prevent and treat blood clots).
The deficient practice had the potential to result in a delay in care and treatment decreasing quality of life.
Findings:
During a review of Resident 385's admission Record (AR), the AR indicated the facility admitted the resident on 10/3/2024, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), depression (a mental health condition that involves a persistent low mood, loss of interest in activities, and difficulty with daily life), and atrial fibrillation (a type of irregular heartbeat that occurs when the upper chambers of the heart [atria] beat rapidly and irregularly).
During a review of Resident 385's Order Summary Report, dated 10/3/2024, the report indicated an order for:
-Oxygen at 2-3 liter per minute (L/min, a measurement of the velocity at which air flows into the sample probe) via nasal cannula (a device that gives additional oxygen through the nose) to keep oxygen saturation level (O2 sats, a measurement of how much oxygen the blood is carrying as a percentage) above 92%. Diagnosis chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). Continuous.
-Donepezil HCl oral tablet 5 milligrams (mg, a unit of weight) (Donepezil Hydrochloride). Give 1 tablet by mouth one time a day for dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities).
-Mirtazapine oral tablet 15 mg (Mirtazapine). Give 1 tablet by mouth at bedtime for depression monitor for behavior (m/b) poor appetite.
-Trazadone HCl tablet 50 mg (Trazadone HCl). Give 0.5 tablet by mouth at bedtime for depression m/b inability to sleep.
-Warfarin sodium oral tablet 2 mg (Warfarin Sodium). Give 3.5 tablet by mouth in the evening for atrial fibrillation.
During a review of Resident 385's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/9/2024, the MDS indicated the resident had intact cognition (the ability to maintain a relatively high level of mental processing, including thinking, learning, memory, and perception).
During a concurrent interview and record review on 10/10/2024, at 10:16 a.m., with Registered Nurse 1 (RN 1), Resident 385's Order Summary Report, Medication Administration Record, and Care Plans were reviewed. RN 1 stated there was an order for Oxygen at 2-3 L/min via nasal cannula, Donepezil HCl 5 mg oral tablet, Mirtazapine 15 mg oral tablet, Trazadone HCl 50 mg tablet, and Warfarin sodium 2 mg oral tablet, however, there were no baseline care plans developed for its use. RN 1 stated baseline care plans should have been created for each to provide a structured framework for addressing each intervention, such as setting goals, monitoring for progress, to improve treatment.
During a review of Resident 385's History and Physical (H&P), dated 10/11/2024, the H&P indicated the resident had the ability to understand and make decisions.
During a concurrent interview and record review, on 10/11/2024, at 2:09 p.m., with the Director of Nursing (DON), Resident 385's Order Summary Report, Medication Administration Record, and Care Plans were reviewed. The DON also stated there was an order to infuse Oxygen at 2-3 L/min via nasal cannula and an order to administer donepezil HCl 5 mg oral tablet, mirtazapine 15 mg oral tablet, trazadone hcl 50 mg tablet, and warfarin sodium 2 mg oral tablet, but there was no baseline care plan developed and implemented prior to its use. The DON stated care plans should have been developed for each intervention to ensure the resident receives the right care and support to meet the resident's needs.
During a review of the facility's recent policy and procedure (P&P) titled Care Plans- Baseline, last reviewed on 4/2024, the P&P 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.
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** 4. During a review of Resident 66's admission Record, the admission Record indicated the facility admitted the resident on 12/21...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a review of Resident 66's admission Record, the admission Record indicated the facility admitted the resident on 12/21/2022, and readmitted the resident on 7/31/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), depression, and anxiety disorder (a condition where a person has excessive and persistent feelings of fear, dread, and uneasiness).
During a review of Resident 66's H&P, dated 1/16/2023, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 66's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class antidepressant medication.
During a review of Resident 66's Order Summary Report, dated 7/31/2024, the Order Summary Report indicated an order for Mirtazapine oral (by mouth) tablet 7.5 milligrams (mg, a unit of weight). Give 1 tablet by mouth at bedtime for depression monitor for behavior (m/b) inability to sleep.
During a concurrent interview and record review on 10/10/2024, at 9:16 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 66's Order Summary Report and Care Plans. RN 1 stated there was an order for Mirtazapine oral tablet 7.5 mg for the resident; however, he cannot find the comprehensive care plan on its use. RN 1 stated it is important to have a care plan on the use of antidepressant (Mirtazapine) because the care plan serves as the medium to communicate the goals of treatment and a way to monitor the progress of care. RN 1 also stated Mirtazapine had a black box warning, meaning it could cause life-threatening adverse effects (a harmful or abnormal result) on residents.
During a concurrent interview and record review on 10/11/2024 at 2:08 p.m., with the DON, reviewed Resident 66's Order Summary Report and Care Plans. The DON stated there was an order for Mirtazapine oral tablet 7.5 mg, but she cannot find the care plan on its use. The DON stated it is important to develop and implement a care plan on Mirtazapine to identify goals and interventions to address its use, and the medication had a black box warning that can cause life-threatening adverse effect.
During a review of the facility's recent policy and P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21days after admission.
5. During a review of Resident 75's admission Record, the admission Record indicated the facility admitted the resident on 9/18/2024 with diagnoses including but not limited to DM 2, generalized muscle weakness, and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
During a review of Resident 75's History and Physical (H&P) dated 9/27/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 75's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/24/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up or clean up assistance with personal hygiene; supervision/touching assistance with eating, oral hygiene , roll left and right, sit to lying , lying to sitting on edge of bed; substantial/maximal assistance with toileting hygiene, and shower/bathing self; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 75 had a diagnosis of DM 2 and received insulin.
During a review of Resident 75's Order Summary Report, the Order Summary Report indicated the following physician's order:
o
9/17/2024 and discontinued 10/7/2024: Insulin Aspart injection solution 100 units/ml inject as per sliding scale:
If 70 - 150 = zero (0) units (a unit of measurement) if blood sugar (BS) less than (<) 70 give eight (8) ounces (oz - a unit of measurement) orange juice (OJ);
151 - 200 = 2 units;
201 - 250 = 4 units;
251 - 300 = 6 units;
301 - 350 = 8 units;
351 - 400 = 10 units. If BS more than (>) 400 give 12 units and call physician subcutaneously (SQ) before meals and at bedtime for DM rotate site. If ineffective and able to swallow administer glucagon (a hormone that helps maintain blood sugar levels and is used to treat low BS and other health conditions) 1 tube PO or glucagon 1 milligram (mg - a unit of measurement) ampule (a sealed glass container used for the safe storage of medications) intramuscularly (IM - a technique used to deliver a medication deep into the muscles), if unable to swallow or unresponsive. Call physician for BS < 70 and inject seven (7) units SQ before meals for DM. Rotate site, give OJ if BS <70. If ineffective and able to swallow administer glucagon 1 tube PO or glucagon 1 mg amp IM if unable to swallow or unresponsive. Call physician for BS < 70.
o
10/7/2024: Insulin Aspart injection solution 100 unit per milliliter (units/ml - a unit of measurement) inject nine (9) units SQ before meals for DM rotate site. Give OJ if BS < 70, If ineffective and able to swallow administer glucagon 1 tube by mouth (PO) or glucagon 1 milligram (mg - a unit of measurement) ampule IM, if unable to swallow or unresponsive. Call physician for BS <70.
o
9/17/2024: Levemir (a long-acting insulin that can be taken once or twice daily to control high blood sugar in adults and children with diabetes) Flex-Pen SQ solution pen injector 100 unit/ml (insulin detemir) inject 21 units SQ in the morning for DM.
o
10/7/2024: 9/17/2024: Levemir (a long-acting insulin that can be taken once or twice daily to control high blood sugar in adults and children with diabetes) Flex-Pen SQ solution pen injector 100 unit/ml (insulin detemir) inject 21 units SQ in the morning for DM.
During a concurrent interview and record review on 10/11/2024 at 11:48 a.m., Resident 75's care plan was reviewed with Minimum Data Set Nurse 1 (MDSN 1). MDSN 1 stated there was no care plan developed and implemented addressing Resident 75's DM and the use of insulin. MDSN 1 stated a care plan should have been developed within 21 days of admission. MDSN 1 stated a care plan is important as it is the center of the resident's plan of care while in the facility, evaluate the effectiveness of interventions, ensure the goal is met for the resident's care and prevent delay in the provision of care the resident needs.
During a concurrent interview and record review on 10/11/2024 at 2:10 p.m., Resident 75's care plan was reviewed with the Director of Nursing (DON), the DON stated there was no care plan addressing Resident 75's DM and the use of Levemir and Insulin Aspart. The DON stated the facility has 21 days to develop and implement a care plan addressing Resident 75's DM and use of insulin as it was the facility's approach regarding resident's plan of care, to identify goals, and interventions while in the facility. The DON stated the care plan assists the facility to monitor if the interventions were effective to prevent a delay in the delivery of necessary care and services the resident needs.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed 4/2024, the P&P indicated:
o
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.
o
The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21days after admission.
Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive person-centered care plan for two of nine sampled residents (Resident 102 and 107) investigated under the accidents care area, two of two (Resident 17 and 23) sampled residents investigated under the activities of daily living (ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care area, and two of five sampled residents (Resident 66 and 75) investigated under the unnecessary medications care area when the facility failed to:
1. Develop Resident 102's care plan for medication storage at the bedside.
2. Develop Resident 107's care plan for use of bed rails (also known as side rails, a type of safety device that can be attached to a bed frame to help prevent falls and provide support for getting in, out, or around the bed).
3. Implement Resident 17 and 23s' care plans for ADL care.
4. Develop and implement Resident 66's care plan on the use of Mirtazapine, an antidepressant medication (prescription medications that treat depression and other mental health conditions).
5. Develop Resident 75's care plan addressing the resident's type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high) and use of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood).
These deficient practices had the potential for a delay in care and services of residents.
Cross-reference F550, F561, F677, F689, and F700.
Findings:
1.During a review of Resident 102's admission Record, the admission record indicated the facility originally admitted Resident 102 on 2/21/2024 with diagnoses including, but not limited to, type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (high blood pressure).
During a review of Resident 102's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/27/2024, the MDS indicated Resident 102 was able to understand and make decisions, required setup assistance with eating, and required moderate to maximal assistance or was dependent on staff for activities of daily living such as hygiene, showering/bathing himself, dressing, toileting, and surface-to-surface transfers.
During a review of Resident 102's History and Physical (H&P), dated 2/21/2024, the H&P indicated Resident 102 had the capacity to understand and make his own medical decisions.
During a review of Resident 102's Self Administration of Medication form, dated 8/27/2024, the self-administration of medication form indicated Resident 102 was not granted approval to self-administer medication.
During a review of Resident 102's Order Summary Report, current as of 10/9/2024, the order summary report did not indicate an order for gas relief medication, artificial tears eye drops, or skin protectant.
During a review of Resident 102's Care Plans, current as of 10/9/2024, the care plans did not indicate the resident can self-administer medication or keep medications at the bedside.
During an observation on 10/8/2024, at 9:05 a.m., inside Resident 102's room, Resident 102 was sleeping in bed with the bedside table positioned to the right of the resident. The bedside table had a bottle of gas relief medication and a tube of skin protectant.
During a concurrent observation and interview with Resident 102, on 10/8/2024, at 12:26 p.m., inside Resident 102's room, a bottle of gas relief medication and a bottle of artificial tears eye drops were on top of Resident 102's bedside table and a tube of skin protectant was below the television placed on a dresser to the left of the resident. Resident 102 confirmed he had the medications at the bedside and stated he was allowed to keep his medications at the bedside.
During an observation on 10/20/2024, at 1:34 p.m., inside Resident 102's room, a bottle of gas relief medication and a bottle of artificial tears eye drops were on a table placed to the right of the resident.
During a concurrent interview and record review with the Minimum Data Set Director (MDSD), on 10/11/2024, at 9:22 a.m., Resident 102's Self Administration of Medication form, dated 8/27/2024, was reviewed and the MDSD confirmed Resident 102 was not granted approval to self-administer medications and stated the resident should not have medications at the bedside. The MDSD further stated medication should be stored where no other residents can access the medications.
During a concurrent observation and interview with the MDSD, on 10/11/2024, at 9:34 a.m., inside Resident 102's room, the MDSD confirmed Resident 102 had a bottle of gas relief medication, a bottle of artificial tears eye drops, and three tubes of skin protectant at the bedside, on top of the bedside table and under the television. The MDSD stated Resident 102 has not been approved for medication self-administration and should not have the medication kept at the bedside. The MDSD stated if Resident 102 was approved for medication self-administration, his medication should be stored in a secure place because there is a possibility that other residents can take his medication and take it on their own.
During an interview with the Director of Nursing (DON), on 10/11/2024, at 3:28 p.m., the DON stated a care plan should be developed for Resident 102 to keep his medications at the bedside because a care plan is a guide for the facility on how to provide interventions to address identified problems for the residents. The DON further stated without a care plan the facility staff would not know how to take care of the residents.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed 4/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
During a review of the facility's P&P titled, Self-Administration of Medications, last reviewed 4/2024, the P&P indicated if it deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan.
2. During a record review of Resident 107's admission Record, the admission record indicated the facility originally admitted Resident 107 on 10/24/2023 and readmitted the resident on 10/31/2023 with diagnoses including, but not limited to, hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (also known as a cerebral vascular accident or stroke, loss of blood flow to a part of the brain) affecting the left dominant side.
During a review of Resident 107's MDS, dated [DATE], the MDS indicated Resident 107 had difficulty understanding and making decisions, was dependent on facility staff for activities of daily living such as eating, hygiene, showering/bathing himself, toileting, dressing, and required maximal assistance with rolling left to right in bed.
During a review of Resident 107's H&P, dated 10/25/2023, the H&P indicated Resident 107 was forgetful, confused, and needs frequent reorientation to reality.
During a review of Resident 107's Order Summary Report, dated 10/31/2023, the order summary report indicated Resident 107 was ordered bilateral quarter side rails locked when in bed as an enabler for mobility during activity of daily living performance and during repositioning. The order summary report further indicated informed consent was obtained from the resident after explaining of risks and benefits and to monitor for presence, placement, and functionality every shift.
During a review of Resident 107's Bedside Rail Entrapment Risk Evaluation, dated 8/7/2024, the bedside rail entrapment risk evaluation indicated Resident 107 requires limited to total dependence with movement, is alert, oriented, able to follow commands and understand the use and purpose of bedside rail, requires supervised assist and cueing in using call alarms, and uses the bedside rail daily, less than 24 hours.
During a review of Resident 107's care plans, current as of 10/11/2024, the care plans did not indicate focuses or interventions related to Resident 107's bed rails.
During a concurrent observation and interview with the MDSC, on 10/11/2024, at 8:38 a.m., inside Resident 107's room, the MDSC confirmed Resident 107 had quarter rails at the head of his bed and uses the rail to move himself around the bed.
During an interview with the DON, on 10/11/2024, at 3:28 p.m., the DON stated a care plan for the use of bed rails should be developed for residents using beds with bed rails to guide the staff on how to provide interventions to address identified problems for the residents.
During a review of the facility's P&P titled, Bed Safety and Bed Rails, last reviewed 4/2024, the P&P indicated before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The P&P further indicated information will be included in the consent:
a.
The assessed medical needs that will be addressed with the use of bed rails.
b.
The resident's risks from the use of bed rails and how those will be mitigated.
3. a. During a review of Resident 17's admission Record, the admission record indicated the facility originally admitted Resident 17 on 5/30/2023 and readmitted the resident on 6/14/2023 with diagnoses including, but not limited to, acute respiratory distress syndrome (a life-threatening lung condition that occurs when the lungs are damaged and can't provide enough oxygen to the body), hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right ankle.
During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 had difficulty understanding and making decisions, had functional limitation in range of motion for one on her upper extremities and both of her lower extremities, and was dependent on facility staff for activities of daily living such as eating, personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands), toileting, showering/bathing herself, dressing, and surface-to-surface transfers.
During a review of Resident 17's H&P, dated 6/15/2023, the H&P indicated Resident 17 did not have the capacity to understand and make decisions.
During a review of Resident 17's Care Plan, last revised 7/10/2024, the care plan indicated Resident 17 has an activity of daily living self-care performance deficit related to, but not limited to, impaired balance, limited mobility, limited range of motion, and cerebrovascular accident. The care plan indicated interventions including, but not limited to, assistance by staff to maintain personal hygiene such as combing hair, shaving, applying makeup, washing, and drying face and hands.
During an observation on 10/8/2024, at 8:32 a.m., inside Resident 17's room, Resident 17 was sleeping in bed and had gray strands of hair above her upper lip and on her chin.
During an observation on 10/9/2024, at 9:45 a.m., inside Resident 17's room, Resident 17 was awake in bed and had gray strands of hair above her upper lip and on her chin.
During an observation on 10/9/2024, at 1:22 p.m., inside Resident 17's room, Resident 17 was awake in bed and had gray strands of hair above her upper lip and on her chin.
During a concurrent observation and interview with Certified Nursing Assistant (CNA) 10, on 10/9/2024, at 1:24 p.m., inside Resident 17's room, CNA 10 confirmed Resident 17 had facial hair above her upper lip and chin and stated the resident should not have facial hair. CNA 10 stated women should not have facial hair. CNA 10 stated female residents should be checked every day for facial hair and should be shaved, as needed, when cleaning their face. CNA 10 further stated if female residents are not shaved, there is a potential for the resident to feel embarrassed.
During an interview with the DON, on 10/11/2024, at 3:28 p.m., the DON stated Resident 17's interventions planned for ADL care should be implemented. The DON further stated if the interventions are not implemented it can potentially cause residents to feel bad and experience low self-esteem.
During a review of the facility's P&P titled, Activities of Daily Living (ADLs), Supporting, last reviewed 4/2024, the P&P indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene.
3.b During a review of Resident 23's admission Record, the admission Record indicated the facility admitted the resident on 1/19/2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities).
During a review of Resident 23's MDS, dated [DATE], the MDS indicated the resident's preferences to choose what clothes to wear was very important. The MDS indicated the resident was able to make self understood and usually understood others. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with upper body dressing, lower body dressing, and putting on/taking off footwear.
During a review of Resident 23's ADL self-care performance deficit care plan, revised 2/1/2024, the care plan indicated the resident goals of not developing complications related to decreased ADL performance The interventions included assisting the resident to choose simple comfortable clothing that enhances the resident's ability to dress self.
During an interview on 10/8/2024 at 3:22 p.m., Responsible Party 1 (RP 1) stated she has repeatedly requested the nursing staff (licensed nurses and certified nursing assistants) for Resident 23 to wear her night gown at night and not a hospital gown (a facility-provided robe worn by patients in a hospital). RP 1 stated the resident was wearing a hospital gown most of the time when she comes and visit the resident. RP 1 stated the resident has personal clothes to wear.
During a concurrent observation and interview, at Resident 23's bedside, on 10/9/2024 at 8:02 a.m., with CNA 13, CNA 13 stated she started her shift at 7:20 a.m. that day and she was the assigned CNA for Resident 23. CNA 13 stated she has not changed the resident yet. CNA 13 stated Resident 23 was wearing a hospital gown with a long-sleeve pink shirt underneath. CNA 13 stated Resident 23 wore the same clothes the previous afternoon and throughout the night.
During a concurrent observation and interview, at Resident 23's bedside, on 10/9/2024 at 4:20 p.m., with CNA 13, CNA 13 stated resident was wearing a green hospital gown. CNA 13 stated she changed Resident 23 into a new gown. CNA 13 stated Resident 23 had clothes in the closet. CNA 13 stated she would change the resident's clothes during the day shift, but because it was already after 3 p.m. she did not need to. CNA 13 stated she did not know Resident 23 had clothes in their closet. CNA 13 stated she did not check the resident's closet before putting on the hospital gown on Resident 23.
During an interview on 10/9/2024 at 4:50 p.m., with MDS Nurse 1 (MDSN 1), MDSN 1 stated CNAs should encouraged and offer resident's their own personal clothing to wear because it is their right and to be treated with dignity and respect. MDSN 1 stated CNA should have checked the closet and assist the resident to wear their clothing.
During an interview on 10/11/2024 at 2:05 p.m., the DON stated the importance of honoring resident's personal clothing to boost the dignity of the patient.
During a review of the facility's recent policy and P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21days after admission.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with profession...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for two of two sampled resident (Residents 70 and 75) reviewed under the insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area and one of one sampled residents (Resident 70) reviewed under the anticoagulant (a drug used to prevent blood clots) care area by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (SQ - beneath the skin) administration sites.
These deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and enoxaparin (a drug used to prevent blood clots) such as bruising, lipodystrophy (abnormal distribution of fat), and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).
Cross Reference F760
Findings:
a. During a review of Resident 70's admission Record (AR), the AR indicated the facility admitted the resident on 5/30/2024, with diagnoses including type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and surgical amputation (the surgical removal of all or part of a limb or extremity such as an arm, leg, foot, hand, toe, or finger).
During a review of Resident 70's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) and hypoglycemic medications (drugs that help lower sugar levels).
During a review of Resident 70's Order Summary Report, the Order Summary Report indicated an order for:
5/3/2024 Enoxaparin (anticoagulant) sodium injection solution prefilled syringe 40 milligrams (mg, a unit of weight)/0.4 milliliters (ml, a unit of volume) (Enoxaparin Sodium). Inject 40 mg subcutaneously in the afternoon for deep vein thrombosis prophylaxis (dvt ppx, reduces the risk of developing deep vein thrombosis through medications, compression stockings, and devices).
8/16/2024 Insulin lispro (rapid-acting insulin) injection solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale (a progressive increase in pre-meal or nighttime insulin doses): if 60-120= 0; less than (<) 70, may give 8 ounces (oz., a unit of weight) orange juice as tolerated; 125-150= 2 units (the standard amount required for a precise measure of activity); 151-200= 4 units; 201-250= 6 units; 251-300= 8 units; 301-350= 10 units; 351-400= 12 units; greater than (>) 400, call MD. Subcutaneously in the evening for diabetes mellitus (DM) before dinner.
10/3/2024 Lantus (long-acting insulin) subcutaneous solution 100 unit/ml (Insulin Glargine). Inject 28 units subcutaneously at bedtime for DM.
During a review of Resident 70's Location of Administration Report for insulin and enoxaparin from 8/2024 to 10/2024, the report indicated insulin and enoxaparin were administered on:
Insulin Lispro Injection Solution 100 unit/ml
8/3/2024 at 5:08 p.m. on the Arm - right
8/4/2024 at 6:46 p.m. on the Arm - right
8/11/2024 at 5 p.m. on the Arm - left
8/12/2024 at 5:51 p.m. on the Arm - left
8/13/2024 at 5:06 p.m. on the Arm - left
8/15/2024 at 6:49 p.m. on the Arm - left
8/18/2024 at 4:07 p.m. on the Arm - left
8/19/2024 at 5:08 p.m. on the Abdomen - Left Upper Quadrant (LUQ)
8/20/2024 at 4:33 p.m. on the Abdomen - LUQ
9/3/2024 at 4:50 p.m. on the Arm - left
9/4/2024 at 5:03 p.m. on the Arm - left
9/23/2024 at 4:23 p.m. on the Arm - right
9/25/2024 at 6:13 p.m. on the Arm - right
Lantus Subcutaneous Solution 100 unit/ml
8/13/2024 at 9:31 p.m. on the Arm - right
8/14/2024 at 9:52 p.m. on the Arm - right
8/16/2024 at 8:37 p.m. on the Arm - right
8/20/2024 at 10:15 p.m. on the Arm - left
8/21/2024 at 8:28 p.m. on the Arm - left
Enoxaparin Sodium Injection Solution Prefilled Syringe 40 mg/0.4 ml
9/6/2024 at 7:53 p.m. on the Abdomen - LUQ
9/7/2024 at 11:01 p.m. on the Abdomen - LUQ
9/12/2024 at 5:46 p.m. on the Abdomen - Right Lower Quadrant (RLQ)
9/13/2024 at 6:26 p.m. on the Abdomen - RLQ
9/20/2024 at 4:37 p.m. on the Abdomen - Left Lower Quadrant (LLQ)
9/21/2024 at 4:45 p.m. on the Abdomen - LLQ
During a concurrent interview and record review on 10/10/2024 at 10:51 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 70's Order Summary Report and Location of Administration Report for insulin and enoxaparin from 8/2024 to 10/2024. RN 1 stated there was an order for Enoxaparin sodium injection solution prefilled syringe 40 mg/0.4 ml, Insulin Lispro Injection Solution 100 unit/ml, and Lantus Subcutaneous Solution 100 unit/ml. RN 1 stated there were multiple instances that the insulin and enoxaparin subcutaneous administrations were not rotated during the period of 8/2024 to 10/2024. RN 1 stated the licensed staff should rotate the insulin and enoxaparin administration sites to prevent bruising and lipodystrophy.
During a concurrent interview and record review on 10/11/2024 at 2:10 p.m., with the Director of Nursing (DON), reviewed Resident 70's Order Summary Report and Location of Administration Report for insulin and enoxaparin from 8/2024 to 10/2024. The DON stated there were multiple instances that insulin and enoxaparin subcutaneous administrations were not rotated during 8/2024 to 10/2024. The DON stated the licensed nurses should rotate enoxaparin and insulin administration sites to prevent muscle shrinking and bruising of the skin.
During a review of the facility's recent policy and procedure (P&P) titled Insulin Administration, last reviewed on 4/2024, the P&P indicated to select an injection site:
a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel.
b. Injection sites should be rotated preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility provided information sheet How to use your Lantus Solostar pen, copyright 2022, the sheet indicated to rotate your injection sites with each dose to reduce your risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.
b. During a review of Resident 75's AR, the AR indicated the facility admitted the resident on 9/18/2024 with diagnoses including DM 2, generalized muscle weakness, and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
During a review of Resident 75's History and Physical (H&P) dated 9/27/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 75's MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up or clean up assistance with personal hygiene; supervision/touching assistance with eating, oral hygiene, rolling left and right, sitting to lying , lying to sitting on edge of bed; substantial/maximal assistance with toileting hygiene, and shower/bathing self; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 75 had a diagnosis of DM 2 and received insulin.
During a review of Resident 75's Order Summary Report, the Order Summary Report indicated the following physician's order:
-9/17/2024 and discontinued 10/7/2024: Insulin Aspart (rapid-acting insulin) injection solution 100 units/ml inject as per sliding scale (refers to the increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal):
If 70 - 150 = zero (0) units (a unit of measurement) if blood sugar (BS) less than (<) 70 give eight (8) ounces (oz - a unit of measurement) orange juice (OJ);
151 - 200 = 2 units;
201 - 250 = 4 units;
251 - 300 = 6 units;
301 - 350 = 8 units;
351 - 400 = 10 units. If BS more than (>) 400 give 12 units and call physician subcutaneously (SQ) before meals and at bedtime for DM rotate site. If ineffective and able to swallow administer glucagon (a hormone that helps maintain blood sugar levels and is used to treat low BS and other health conditions) 1 tube PO (by mouth) or glucagon 1 milligram (mg - a unit of measurement) ampule (a sealed glass container used for the safe storage of medications) intramuscularly (IM - a technique used to deliver a medication deep into the muscles), if unable to swallow or unresponsive. Call physician for BS < 70 and inject seven (7) units SQ before meals for DM. Rotate site, give OJ if BS <70. If ineffective and able to swallow administer glucagon 1 tube PO or glucagon 1 mg amp IM if unable to swallow or unresponsive. Call physician for BS < 70.
-10/7/2024: Insulin Aspart injection solution 100 unit per milliliter (units/ml - a unit of measurement) inject nine (9) units SQ before meals for DM rotate site. Give OJ if BS < 70, If ineffective and able to swallow administer glucagon 1 tube by mouth (PO) or glucagon 1 milligram (mg - a unit of measurement) ampule IM, if unable to swallow or unresponsive. Call physician for BS <70.
-9/17/2024: Levemir (a long-acting insulin) Flex-Pen SQ solution pen injector 100 unit/ml (insulin detemir) inject 21 units SQ in the morning for DM.
-10/7/2024: 9/17/2024: Levemir Flex-Pen SQ solution pen injector 100 unit/ml (insulin detemir) inject 21 units SQ in the morning for DM.
During a review of Resident 75's Medication Administration Record (MAR) from 9/2024 and 10/2024, the MAR indicated Insulin Aspart and Levemir injection solution were administered as follows:
-Insulin Aspart injection solution 100 unit/ml
10/4/24 11:19 am SQ Abdomen - left lower quadrant (LLQ)
10/4/24 4:55 p.m. SQ Abdomen - LLQ
9/20/24 4:19 p.m. SQ Abdomen - right lower quadrant (RLQ)
9/21/24 7:28 a.m. SQ Abdomen - RLQ
9/23/24 11:19 a.m. SQ Abdomen - RLQ
9/23/24 5:16 p.m. SQ Abdomen - RLQ
9/24/24 4:00 p.m. SQ Abdomen - LLQ
9/25/24 8:55 a.m. SQ Abdomen - LLQ
9/28/24 11:26 a.m. SQ Arm - left
9/28/24 4:35 a.m. SQ Arm - left
9/30/24 7:46 a.m. SQ Abdomen - LLQ
9/30/24 4:20 p.m. SQ Abdomen - LLQ
-Levemir FlexPen SQ solution pen-injector 100 unit/ml
10/1/24 6:41a.m. SQ Abdomen - LLQ
10/2/24 6:38 a.m. SQ Abdomen - LLQ
10/5/24 7:23 a.m. SQ Abdomen - left upper quadrant (LUQ)
10/6/24 7:46 a.m. SQ Abdomen - LUQ
During a concurrent interview and record review on 10/11/2024 at 11:43 a.m., reviewed Resident 75's physician's orders, MAR, and location of administration sites for Insulin Aspart and Levemir injection solution from 9/2024 to 10/2024 with the Minimum Data Set Nurse 1 (MDSN 1), MDSN 1 verified the insulin injection sites were not rotated. MDSN 1 stated the insulin injection sites should have been rotated. MDSN 1 stated not rotating the insulin injection site can damage the tissues such as lumps and bruising.
During an interview on 10/11/2024 at 2:10 p.m., the DON stated the licensed nurses failed to rotate the injection sites. The DON stated the insulin injection sites should have been rotated as it placed the resident at risk for bruising, swelling, or any trauma to the skin. The DON stated not rotating the sites can cause lipodystrophy.
During a review of the facility's P&P titled Insulin Administration, last reviewed 4/2024, the P&P indicated to select an injection site:
a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel.
b. Injection sites should be rotated preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility-provided manufacturer's guideline titled, Insulin Aspart Injection, undated, last reviewed on 4/2024, the manufacturer's guideline indicated for subcutaneous injection, rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
During a review of the facility-provided manufacturer's guideline titled, How to Use Levemir FlexPen, undated, indicated:
o Levemir can be injected under the skin of the stomach area, upper legs, or upper arms.
o Change (rotate) the injection site with each injection.
During a review of the facility's policy and procedure titled Adverse Consequences and Medication Errors, last reviewed 4/2024, indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for nine (9) of twelve (12) sampled residents (Residents 66, 75, 114, 70, 80, 103, 68, 80, and 96) investigated under accidents by failing to ensure:
1. Resident 66, 75, and 114's fall mat (a floor mat designed to reduce the risk of injury from fall by providing a soft-landing surface) did not have medical equipment or furniture on top of them for a longer period of time.
These deficient practices had increased the chances of the resident incurring an injury such as falls with fracture (a break or crack in a bone) and even death.
2. Resident 70, 80, 102, 103, and 68's medications were not left unattended at the resident's bedside.
These deficient practice increases the risks of harm to the resident from omitting the dose, double dosing, and mixing the medications that could cause adverse (unfavorable) or even fatal effects on the resident.
3. Resident 96's floor was not left wet after Certified Nursing Assistant 12 (CNA 12) provided activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
4. Resident 75's sensor pad alarm (a device that triggers an audible alarm when a patient attempts to rise off the pad) in bed was properly functioning.
These deficient practices had a potential for resident at increased risk for further falls.
Findings:
1.a During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted the resident on 12/21/2022, and readmitted the resident on 7/31/2024, with diagnoses including displaced fracture of right femur (a broken femur [thigh bone] where the bone fragments have moved out of alignment), muscle weakness, and history of falling.
During a review of Resident 66's History and Physical (H&P), dated 1/16/2023, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 66's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had an impairment on one side of the lower extremity and uses walker and wheelchair to ambulate. The MDS indicated the resident was dependent to requiring substantial to maximal assistance on mobility and activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 66's Order Summary Report, dated 7/31/2024, the Order Summary Report indicated an order for bilateral landing pads (fall mat) by bedside, monitor presence and displacement to minimize injury every shift for fall precaution.
During a concurrent observation and interview on 10/10/2024 at 2:14 p.m., with Registered Nurse 1 (RN 1), inside Resident 66's room, observed Resident's fall mat at the right side of the bed with a bedside table on top of them. RN 1 stated having a furniture like the bedside table on top of the fall mat increases the risk for injury of the resident hitting the hard surfaces of the furniture causing fracture or trauma. RN 1 also stated placing a heavy equipment or furniture on top of the fall mat compromises the ability of the mat to lessen the impact of the fall due to permanent dents caused by the equipment or furniture on top of them.
During an interview on 10/11/2024 at 2:20 p.m., with the Director of Nursing (DON), the DON stated there should be no side table on top of the fall mat because the fall mat will cause the bedside table to be unstable and could fall on the resident. The DON also stated the bedside table can leave a permanent dent on the fall mat that can decrease the cushioning effect of the fall mat when the resident falls.
During a review of the facility's recent policy and procedure (P&P) titled Safety and Supervision of Residents, last reviewed on 4/2024, the P&P indicated safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes;
Quality Assurance and Performance Improvement (QAPI - process used to ensure services and care are meeting quality standards) reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.
During a review of the facility-provided Manufacturer's Specification on the use of Floor Mat 1 (FM 1), undated, the specification indicated to never leave heavy materials on the mat for an extended amount of time and they may cause a permanent indentation.
During a review of the facility-provided Manufacturer's Specification on the use of Floor Mat 2 (FM 2), undated, the specification indicated to never leave heavy materials on the mat for an extended amount of time and they may cause a permanent indentation.
2.a During a review of Resident 70's admission Record, the admission Record indicated the facility admitted the resident on 5/3/2024, with diagnoses including surgical amputation (the surgical removal of all or part of a limb or extremity such as an arm, leg, foot, hand, toe, or finger) and muscle weakness.
During a review of Resident 70's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others.
During a review of Resident 70's Order Summary Report, dated 6/6/2024, the Order Summary Report indicated an order for artificial tears ophthalmic solution 1.4% (Polyvinyl Alcohol). Instill 2 drops on both eyes every 4 hours as needed for dry eyes.
During a review of Resident 70's Self-Administration of Medication, dated 5/3/2024, the assessment indicated resident did not meet the criteria to self-administer medications. Licensed nurses will continue to administer medications as ordered.
During a concurrent observation and interview on 10/8/2024 at 10:21 a.m., with Certified Nursing Assistant 11 (CNA 11), inside Resident 70's room, observed Resident 70's artificial tears ophthalmic solution 1.4% (Polyvinyl Alcohol) on top of the bed side drawer of the resident. CNA 11 stated it was the resident's preference and the resident gets mad when they take it out.
During an interview and record review on 10/10/2024 at 10:46 a.m., with RN 1, reviewed Resident 70's Order Summary Report and Self-Administration of Medication Assessment. RN 1 stated there was an order for artificial tears ophthalmic solution 1.4% (Polyvinyl Alcohol); however, there was no order for the resident to self-administer medications. RN 1 stated the Self-Administration of Medication Assessment indicated the resident did not meet the criteria. Licensed Nurses will continue to administer medications as ordered. RN 1 stated the medication should have not been left at the bedside to prevent accidents such as over/under dosing of medication and accidental ingestion of the medication by other residents.
During an interview on 10/11/2024 at 4:02 p.m., with the DON, the DON stated if the staff finds medication on top of the resident's bedside tables, they need to notify the charge nurses and document the incident. The DON stated if the resident insists on keeping the medication at the bedside, the licensed staff should do an Interdisciplinary Team meeting (IDT, a group of healthcare professionals from various disciplines who work together to provide patient-centered care) to explain the risks and benefits of keeping the medication at the bedside to the resident or representative. The DON stated the failure of the staff to keep the medication away from the resident may result to the resident administering wrong dose of medication that can result to the resident being overdosed or underdosed.
During a review of the facility's P&P titled Self-Administration of Medications, last reviewed on 4/2024, the P&P indicated self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart in the medication room. A licensed nurse transfers the unopened medications to the resident when the resident requests them. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 4/2024, the P&P indicated safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.
2.b During a review of Resident 80's admission Record, the admission Record indicated the facility admitted the resident on 3/28/2024, with diagnoses including osteomyelitis of the vertebra (a rare infection of the bones in the spine), muscle weakness, and anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress).
During a review of Resident 80's H&P, dated 3/29/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 80's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others.
During a review of Resident 80's Order Summary Report, the Order Summary Report did not indicate an order for SuperLife Super C-Complex with Citrus Bioflavonoids capsules and CVS Stomach Relief 202 mg tablets.
During a review of Resident 80's Self Administration of Medication, dated 7/15/2024, the assessment indicated licensed nurses will continue to administer medications as ordered.
During an observation on 10/8/2024 at 9:57 a.m., observed medications 1 bottle of SuperLife Super C-Complex with Citrus Bioflavonoids capsules and 1 bottle of CVS Stomach Relief 202 mg tablet at the bed side table of the resident.
During a concurrent interview and record review on 10/10/2024 at 11:02 a.m., with RN 1, reviewed Resident 80's Order Summary Report and Self-Administration of Medication Assessment. RN 1 stated there was no order for SuperLlife Super C-Complex with Citrus Bioflavonoids capsules, CVS Stomach Relief 202 mg tablet and there was no order for the resident to Self-Administer medications. RN 1 stated the Self-Administration of Medication Assessment indicated licensed nurses will continue to administer medications as ordered. RN 1 stated the medication should have not been left at the bedside to prevent accidents such as over/under dosing of medication and accidental ingestion of the medication by other residents.
During an interview on 10/11/2024 at 4:02 p.m., with the DON, the DON stated if the staff finds medication on top of the resident's side tables, they need to notify the charge nurses and document the incident. The DON stated if the resident insists on keeping the medication at the bedside the licensed staff should do an IDT to explain the risks and benefits of keeping the medication at the bedside to the resident or representative. The DON stated the failure of the staff to keep the medication away from the resident may result to the resident administering wrong dose of medication that can result to the resident being overdosed or underdosed.
During a review of the facility's recent P&P titled Self-Administration of Medications, last reviewed on 4/2024, the P&P indicated self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart of in the medication room. A licensed nurse transfers the unopened medications to the resident when the resident requests them. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 4/2024, the P&P indicated safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.
2.d During a review of Resident 103's admission Record, the admission Record indicated the facility admitted the resident on 9/18/2023 with diagnoses that included fracture (broken bone) of the right and left pubis (pelvic bone); fracture of one, right side rib; fracture of the second, third, fourth, and fifth lumbar (lower back) vertebra (spinal bone); and depression (persistent feelings of sadness and loss of interest that can interfere with daily living).
During a review of Resident 103's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/25/2024, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required partial/moderate assistance from staff for bathing and dressing, required supervision for toileting, and required setup or clean up assistance for eating and oral hygiene.
During a review of Resident 103's Physician Order Summary Report for October, the report indicated orders for the following:
-Vitamin D tablet, give 1000 units (a unit of measurement) by mouth one time a day for supplement, dated 9/20/2024.
- Ascorbic Acid (vitamin C) tablet 500 milligrams (mg, a unit of measurement), give one tablet by mouth one time a day for skin management), dated 9/20/2024.
-Aspirin (medication to treat or prevent heart attacks and strokes) 81 mg oral tablet chewable, give one tablet by mouth one time a day for deep vein thrombosis (DVT - a blood clot) prevention, dated 1/8/2024.
-Multiple vitamin with minerals, give one tablet orally one time a day for supplement, dated 9/18/2024.
-Sennoside (stool softener) oral tablet 8.6 mg, give one tablet orally two times a day for bowel management, hold for loose stool, dated 9/18/2024.
-Gabapentin oral capsule 100 mg, give one capsule orally three times a day for neuropathy (nerve pain), dated 10/2/2024.
During a review of Resident 103's Self-Administration of Medication form, dated 9/23/2024, the form indicated the resident is unable to correctly state the name of medication, is unable to correctly state what each medication is for, is unable to correctly state the time medications are to be taken, is unable to correctly state the proper dosage of medication, and is unable to demonstrate secure storage for medication kept in the room. The form further indicated self-administration is not granted and the licensed nurse will administer resident's medication as ordered.
During a concurrent observation and interview on 10/8/2024 at 10:15 a.m., observed Resident 103 lying in bed, and on the resident's nightstand, observed a clear plastic medication cup containing five tablets and one capsule. Resident 103 stated the medications were his and the nurse always leaves the medications on the night stand for him.
During a concurrent observation and interview on 10/8/2024 at 10:17 a.m., observed LVN 6 entered Resident 103's room and stated she left the resident's medications in the room for him to take. LVN 6 stated the medication included only vitamins and the resident was able to take his medications on his own. Observed LVN 6 exit Resident 103's room and the medications remained at bedside.
During an observation on 10/8/2024 at 10:22 a.m., observed Resident 103's roommate standing in the doorway, observed Resident 103 self-administering the medication from the plastic cup.
During an interview on 10/8/2024 at 10:54 a.m., LVN 6 sat in Station A and stated she is supposed to watch residents take their medications. LVN 6 stated she knows she is not supposed to leave medications at bedside, but Resident 103 does not want to be forced to take them and so she left the medications in the resident's room. LVN 6 stated when a resident refuses to take their medications the process is to place the medications in the locked medication cart and offer them again later. LVN 6 stated medications should be left in the medication cart until the resident is ready to take them, but she did not do that.
During a concurrent interview and record review on 10/8/2024 at 4:14 p.m., Licensed Vocational Nurse 7 (LVN 7) reviewed Resident 103's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and noted LVN 6 documented the following as administered to Resident 103 on 10/8/2024 for the 9 a.m. medication pass:
-Vitamin D, a 1000 units tablet.
- Ascorbic Acid, a 500 mg tablet.
-Aspirin, an 81 mg tablet
-Multiple vitamins with minerals, one tablet.
-Sennoside, an 8.6 mg tablet.
-Gabapentin, 100 mg capsule.
During an interview on 10/11/2024 at 8:58 a.m., with the Director of Nursing (DON), the DON stated the process for administering medications is if a resident is sleeping and wants to take medications at a later time, then the licensed nurse can hold the medications for up to an hour, however they cannot leave the medications at bedside. The DON stated held medications are to be placed in the locked medication cart for safe keeping, then the nurse can return to the resident at a later time and re-offer the medication. The DON stated when medications are left at bedside for a resident to self-administer, there is a potential that the resident will have side effects that may go unnoticed, it could lead to an overdose if the medication was not taken at the correct time and an additional dose was administered, and other residents could take medication that does not belong to them leading to allergic reactions and side effects like an overdose. The DON stated a lot of things could happen and the facility policy was not followed when LVN 6 left the resident's medication at bedside.
During a review of the facility policy and procedure titled, Self-Administration of Medications, last reviewed 4/2025, indicated residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents.
During a review of the facility policy and procedure titled, Medication Administration, last reviewed 4/2025, indicated medications are administered in a safe and timely manner, and as prescribed. For residents unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. Residents may self-administer their own medications 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.
During a review of the facility policy and procedure titled, Safety and Supervision of Residents, last reviewed 4/2025, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. The IDT care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. Resident supervision is a core component of the systems approach to safety.
2.e During a review of Resident 68's admission Record, the admission Record indicated the facility admitted the resident on 9/2/2020 and readmitted the resident on 11/15/2023 with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified systolic heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), and (hypertension (HTN-high blood pressure).
During a review of Resident 68's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required partial/moderate assistance from staff for bathing and dressing, required supervision for toileting and personal hygiene and required setup or clean up assistance for eating and oral hygiene. The MDS indicated the resident was taking and anticoagulant (blood thinner), a high-risk drug class of medication.
During a review of Resident 68's Physician Order Summary Report, the report indicated orders for the following:
- Dapagliflozin propanediol (a medication to treat DM) oral tablet 10 milligrams (mg, a unit of measurement), give one tablet by mouth one time a day for DM, dated 11/15/2023.
- Digoxin (a medication to treat heart failure) tablet 125 micrograms (mcg, a unit of measurement), give one tablet by mouth one time a day for atrial fibrillation (A-fib - irregular heart rate), hold if apical heart rate is less than 60, dated 11/15/2023.
- Oyster shell calcium tablet 500 mg, give one tablet by mouth one time a day for calcium supplement, dated 11/15/2023.
-Vitamin D tablet, give 1000 units by mouth one time a day for supplement, dated 11/15/2023.
- Docusate sodium (a medication to prevent constipation) oral tablet 100 mg, give one tablet by mouth two times a day for bowel management, hold if loose stool, dated 11/15/2023.
- Eliquis (an anticoagulant) oral tablet five mg, give one tablet by mouth two times a day for A-fib, dated 11/15/2023.
- Potassium Chloride extended release 20 milliequivalent (MEQ - a unit of measurement), give one tablet by mouth two times a day for low potassium level, administer with or after meals with approximately four to eight oz of water or juice as tolerated, dated 11/15/2023.
-Sacubitril - Valsartan (medication to treat heart failure) oral tablet 24-26 mg, give one tablet by mouth two times a day for heart failure, dated 11/16/2023.
During a review of Resident 68's Self Administration of Medication form, dated 9/6/2024, the form indicated the resident is unable to correctly state the time medications are to be taken, is unable to correctly state the proper dosage of medication, and is unable to demonstrate secure storage for medication kept in the room. The form further indicated self-administration is not granted and the licensed nurse will administer residents medication as ordered.
During a concurrent observation and interview on 10/8/2024 10:45 a.m., observed Resident 68 lying in bed with his eyes closed. Observed a plastic medication cup containing eight medications on the bedside rolling table. Resident 68 opened his eyes and stated the medications were his and the nurse left them there for him to take, but he fell back asleep.
During an interview on 10/8/2024 at 10:54 a.m., LVN 6 sat in Station A and stated she left Resident 68's medications at bedside with him to administer himself. Observed LVN 6 walk to Resident 68's room, entered the room without knocking or announcing her entrance, and loudly stated Resident 68's first name in a decibel heard at Station A. The surveyor then walked toward Resident 68's room and observed Resident 68 state that he fell asleep and forgot to take the medications. LVN 6 exited the resident's room and returned to Station A. LVN 6 stated she handed Resident 68 his medications and left the resident's room without watching him take them. LVN 6 stated she is supposed to watch resident's take their medications. LVN 6 stated she knows she is not supposed to leave medications at bedside, but Resident 68 is cranky and she just left them there. LVN 6 stated when a resident refuses to take their medications the process is to place the medications in the locked medication cart and offer them again later. LVN 6 stated medications should be left in the medication cart until the resident is ready to take them, but she did not do that.
During a concurrent interview and record review on 10/8/2024 at 4:14 p.m., Licensed Vocational Nurse 7 (LVN 7) reviewed Resident 68's MAR and noted LVN 6 documented the following as administered to Resident 68 on 10/8/2024 for the 9 a.m. medication pass:
- Dapagliflozin propanediol, a 10 mg tablet.
- Digoxin , a 125-mcg tablet.
- Oyster shell calcium, a 500 mg tablet.
- Vitamin D, a 1000 units tablet.
- Docusate sodium, one 100 mg tablet.
- Eliquis, a five mg tablet.
- Potassium Chloride extended release, a 20 MEQ tablet.
- Sacubitril - Valsartan, one 24-26 mg tablet.
During an interview on 10/11/2024 at 8:58 a.m., the Director of Nursing (DON) stated the process for administering medications is if a resident is sleeping and wants to take medications later, then the licensed nurse can hold the medications for up to an hour, however they cannot leave the medications at bedside. The DON stated held medications are to be placed in the locked medication cart for safe keeping, then the nurse can return to the resident later and re-offer the medication. The DON stated when medications are left at bedside for a resident to self-administer, there is a potential that the resident will have side effects that may go unnoticed, it could lead to an overdose if the medication was not taken at the correct time and an additional dose was administered, and other residents could take medication that does not belong to them leading to allergic reactions and side effects like an overdose. The DON stated a lot of things could happen with high risk medications and the facility policy was not followed when LVN 6 left the resident's medication at bedside.
During a review of the facility policy and procedure titled, Self-Administration of Medications, last reviewed 4/2025, indicated residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents.
During a review of the facility policy and procedure titled, Medication Administration, last reviewed 4/2025, indicated medications are administered in a safe and timely manner, and as prescribed. For residents unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. Residents may self-administer their own medications 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.
During a review of the facility policy and procedure titled, Safety and Supervision of Residents, last reviewed 4/2025, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. The IDT care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. Resident supervision is a core component of the systems approach to safety.
1.b During a review of Resident 75's admission Record, the admission Record indicated the facility admitted the resident on 9/18/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high) generalized muscle weakness, and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
During a review of Resident 75's History and Physical (H&P) dated 9/27/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 75's MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up or clean up assistance with personal hygiene; supervision/touching assistance with eating, oral hygiene, rolling left and right, sitting to lying, lying to sitting on edge of the bed; substantial/maximal assistance with toileting hygiene, and shower/bathing self; and partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 75 had a diagnosis of DM 2 and received insulin.
During a review of Resident 75's Order Summary Report, the Order Summary Report indicated the following physician's order:
9/17/2024: Apply bilateral landing pads (a type of mat or pad that provides cushioning to protect from impact and reduce floor impact) by bedside to minimize injury. Monitor presence very shift.
9/30/2024: Apply sensor pad alarm in bed to remind resident to call for assistance and alert staff when moving or getting up from bed every shift. Monitor for presence, placement, and functionality every shift for fall prevention. Every shift to alert/alarm staff if resident is trying to get out of bed.
During a review of Resident 75's care plan actual fall incident when resident was found sitting on the floor initiated 9/30/2024 last revised 10/1/2024 indicated the following interventions:
Apply bilateral landing pads (a type of mat or pad that provides cushioning to prot
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure residents who require dialysis (also known as renal dialysis and hemodialysis, a treatment to cleanse the blood of wastes and extra ...
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Based on interview and record review, the facility failed to ensure residents who require dialysis (also known as renal dialysis and hemodialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) receive services, consistent with professional standards of practice, for one of two sampled residents (Resident 19) investigated under the dialysis care area when Resident 19's pre and post dialysis weights were not documented into the electronic medical record.
This deficient practice had the potential for the facility's ability to monitor the resident's drastic weight changes from dialysis.
Findings:
During a review of Resident 19's admission Record, the admission record indicated the facility originally admitted Resident 19 on 7/13/2010 and readmitted the resident on 12/23/2023 with diagnoses including, but not limited to, end stage renal disease (ESRD, irreversible kidney failure), dependence on renal dialysis, and generalized muscle weakness.
During a review of Resident 19's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/3/2024, the MDS indicated Resident 19 was able to understand and make decisions, was independent or required setup to moderate assistance with activities of daily living including eating, hygiene, showering/bathing herself, dressing, toileting, and surface-to-surface transfers, and received hemodialysis treatments as a resident.
During a review of Resident 19's History and Physical (H&P), dated 12/24/2023, the H&P indicated Resident 19 has the capacity to understand and make decisions.
During a review of Resident 19's Order Summary Report, dated 12/14/2023, the order summary report indicated Resident 19 was ordered pre and post dialysis weights on dialysis days, two times a day every Tuesday, Thursday, and Saturday.
During a review of Resident 19's Weight Summary, dated between 1/8/2024 to 9/3/2024, the weight summary indicated weight measurements were documented on the following days:
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1/8/2024 (Monday)
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2/6/2024 (Tuesday)
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3/5/2024 (Tuesday)
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4/5/2024 (Friday)
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5/8/2024 (Wednesday)
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5/31/2024 (Friday)
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6/5/2024 (Wednesday)
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7/3/2024 (Wednesday)
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8/5/2024 (Monday)
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9/3/2024 (Tuesday)
The weight summary did not indicate other dates Resident 19's weight was measured and recorded.
During a concurrent interview and record review with the Minimum Data Set Director (MDSD), on 10/11/2024, at 9:01 a.m., Resident 19's Order Summary Report, dated 12/14/2023, was reviewed, and the MDSD confirmed Resident 19 had an order for pre and post dialysis weights on dialysis days, two times a day every Tuesday, Thursday, and Saturday. The MDSD stated the monitoring should be documented in the Medication Administration Record (MAR) or the progress notes. Resident 19's MAR, dated 9/2024, was reviewed and the MDSD confirmed no weights were documented. Resident 19's Weight Summary, dated between 1/8/2024 to 9/3/2024, was reviewed and the MDSD confirmed only monthly weights were documented. The MDSD stated weights should be documents in the electronic medical record for both pre and post dialysis to monitor the resident for significant weight gain or loss. The MDSD further stated if the weights are not documented, the facility would not be able catch any significant changes and would not be able to provide the resident the appropriate interventions.
During an interview with the Director of Nursing (DON), on 10/11/2024, at 3:28 p.m., the DON stated weights should be documented in the dialysis communication form and should be recorded in the MAR or in the weight summary to facilitate communication. The DON further stated if the facility does not input the resident's weight in the electronic medical record, the facility would not be able to monitor drastic weight changes from dialysis.
During a review of the facility's policy and procedure (P&P) titled, End-Stage Renal Disease, Care of a Resident with, last reviewed 4/2024, the P&P indicated residents with ESRD will be cared for according to currently recognized standards of care.
During a review of the facility's P&P titled, Weight Assessment and Intervention, last reviewed 4/2024, the P&P indicated weights are recorded in the individual's medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were assessed, including a review of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were assessed, including a review of risks including entrapment (when a resident is trapped in the spaces in between or around the bed rails [adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes], mattress, or bed frame), provided and maintained a copy of the informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), and failed to obtain a physician's order for the use of bed rails for three of seven residents (Resident 66, 90, and 61) investigated under the physical restraints care area and two of nine sampled residents (Resident 75 and 107) investigated under the accidents care area by failing to:
1. Discontinue the bedrails when not indicated, perform a quarterly bed rail assessment for entrapment, and to obtain a consent from the resident or resident representative of the bedrail's continued use for Resident 66, Resident 90, and Resident 61.
2. Complete the restraint assessment, obtain an informed consent and physician order prior to the use of half (1/2) side rails (SR) for Resident 75.
3. Obtain and maintain a copy of Resident 107's informed consent for use of bed rails.
These deficient practices placed the residents at risk for potential accidents such as a body part being caught between the rails, falls if a resident attempts to climb over, around, between, or through the rails and potentially violate the residents' rights.
Findings:
1. During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted the resident on 12/21/2022, and readmitted the resident on 7/31/2024, with diagnoses including displaced fracture of right femur (a broken femur [thigh bone] where the bone fragments moved out of alignment due to trauma), abnormalities of gait (a manner of walking or moving on foot) and mobility, and history of falling.
During a review of Resident 66's History and Physical (H&P), dated 1/16/2023, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 66's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, the MDS indicated the resident has the ability to make self-understood and understand others. The MDS indicated the resident had severe cognitive impairment (a condition where a person has difficulty with basic tasks and is unable to live independently) and was dependent to requiring substantial to maximal assistance on mobility and activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 66's Bedside Rail Entrapment Risk Evaluation, dated 9/6/2024, the evaluation indicated the bedside rail was not used at all.
During an observation on 10/8/2024, at 8:56 a.m., during resident screening, observed Resident 66 lying in bed with both upper bed rails up.
During a concurrent observation, interview, and record review on 10/10/2024, at 9:39 a.m., with Registered Nurse 1 (RN 1), inside resident 66's room, Resident 66's Order Summary Report and Bed Rail Entrapment Risk Evaluations were reviewed. RN 1 stated the Bed Rail Entrapment Risk Evaluation done on 9/6/2024 indicated the bed rail was not used at all. RN 1 stated the bed rail should have not been applied as it was not appropriate on assessment of the licensed staff. RN 1 stated the continued application of the bed rails on the resident without appropriate assessment can lead to accidents such as entrapment.
During an interview on 10/11/2024, at 2:08 p.m., with the Director of Nursing (DON), the DON stated the Bed Rail Entrapment Risk Evaluation dated 9/6/2024 indicated the resident was not using the bed rail at all and should have been removed. The DON stated the continued use of the side rail without appropriate assessment resulted in inappropriate use predisposing resident to injury such as entrapment.
During a review of the facility's recent policy and procedure (P&P) titled Bed Safety and Bed Rails, last reviewed on 4/2024, the P&P indicated before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent:
a. The assessed medical needs that will be addressed with the use of bed rails;
b. The resident's risk from the use of bed rails and how these will be mitigated.
During a review of the facility provided information Bed Rail 1 (BR 1), last revised on 3/18/2021, the information indicated risk for serious injury. Individuals with physical limitations who cannot prevent themselves from rolling or climbing out the bed may require other means of safe positioning.
During a review of the facility's recent policy and procedure (P&P) titled Resident Assessments, last reviewed on 4/2024, the P&P indicated OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include:
B. Quarterly Assessment.
2. During a review of Resident 90's admission Record (AR), the AR indicated the facility admitted the resident on 10/11/2023, and readmitted the resident on 5/28/2024, with diagnoses including dementia (a progressive state of decline in mental abilities) and schizophrenia (a mental illness that is characterized by disturbances in thought).
During a review of Resident 90's Bedside Rail Entrapment Risk Evaluation, dated 4/17/2024, the evaluation indicated the bedside rail was not used at all.
During a review of Resident 90's H&P, dated 5/29/2024, the H&P indicated the resident can make needs known but cannot make medical decisions.
During a review of Resident 90's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had severe cognitive impairment and the resident required partial to supervision assistance on mobility and activities of daily living (ADLs).
During a review of Resident 90's Fall Risk Evaluation (FRE), dated 8/23/2024, the FRE indicated the resident was a high risk for falls.
During an observation on 10/8/2024, at 9:06 a.m., during resident screening, Resident 66 was observed lying in bed with both upper grab bars (a safety device that provides support and stability to help people maintain balance, reduce fatigue, and avoid falls) up.
During a concurrent observation, interview, and record review on 10/10/2024, at 10:35 a.m., with RN 1, inside Resident 90's room, Resident 90's Order Summary Report and Bed Rail Entrapment Risk Evaluations were reviewed. RN 1 stated the Bed Rail Entrapment Risk Evaluation done on 4/17/2024 indicated the bed rail was not used at all. RN 1 stated the bed rail should have not been applied as it was not appropriate on assessment of the licensed staff. RN 1 also stated a quarterly assessment should have been done on the resident around 7/2024 to evaluate its use, and if needed, another consent on the use of bedrail should have been obtained from the resident or representative.
During an interview on 10/11/2024, at 2:08 p.m., with the DON, the DON stated the Bed Rail Entrapment Risk Evaluation dated 4/17/2024 indicated the resident was not using the bed rail at all and should have been removed. The DON stated the continued use of the side rail without appropriate assessment resulted in inappropriate use, predisposing resident to injury such as entrapment. The DON also added a quarterly assessment of the Bed Rail Entrapment Risk Evaluation should have been done on the resident to evaluate its current use and a consent should have been obtained for its continued use. The DON stated it was important to have a current assessment to ensure safe use of the bedrails and to prevent the resident for injuries such as entrapment.
During a review of the facility's recent policy and procedure (P&P) titled Bed Safety and Bed Rails, last reviewed on 4/2024, the P&P indicated before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent:
a. The assessed medical needs that will be addressed with the use of bed rails;
b. The resident's risk from the use of bed rails and how these will be mitigated.
During a review of the facility's recent policy and procedure (P&P) titled Resident Assessments, last reviewed on 4/2024, the P&P indicated OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include:
B. Quarterly Assessment.
3. During a review of Resident 61's admission Record (AR), the AR indicated the facility admitted the resident on 11/3/2022, and readmitted the resident on 8/28/2024, with diagnoses including abnormal posture and muscle weakness.
During a review of Resident 61's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and to understand others. The MDS indicated the resident had one sided upper extremity impairment and both lower extremity impairment. The MDS further indicated the resident required substantial to partial assistance on mobility and activities of daily living (ADLs).
During a review of Resident 61's Bedside Rail Entrapment Risk Evaluation, dated 4/18/2024, the evaluation indicated the bedside rail was not used at all.
During a review of Resident 61's Fall Risk Evaluation (FRE), dated 8/28/2024, the FRE indicated the resident was a high risk for falls.
During an observation on 10/8/2024, at 9:02 a.m., during resident screening, Resident 61 was observed lying in bed with both upper bedrails up.
During a concurrent observation, interview, and record review, on 10/10/2024, at 10:37 a.m., with RN 1, inside Resident 61's room, Resident 61's Order Summary Report and Bed Rail Entrapment Risk Evaluations were reviewed. RN 1 stated the Bed Rail Entrapment Risk Evaluation done on 4/18/2024 indicated the bed rail was not used at all. RN 1 stated the bed rail should have not been applied as it was not appropriate on assessment of the licensed staff. RN 1 also stated a quarterly assessment should have been done on the resident around 7/2024 to evaluate its use, and if needed another consent on the use of bedrail should have been obtained from the resident or representative.
During an interview on 10/11/2024, at 2:08 p.m., with the DON, the DON stated the Bed Rail Entrapment Risk Evaluation dated 4/18/2024 indicated the resident was not using the bed rail at all and should have been removed. The DON stated the continued use of the side rail without appropriate assessment resulted in inappropriate use predisposing the resident to injury such as entrapment. The DON also added a quarterly assessment of the Bed Rail Entrapment Risk Evaluation should have been done on the resident to evaluate its current use and a consent should have been obtained for its continued use. The DON stated it was important to have a current assessment to ensure safe use of the bedrails and to prevent the resident for injuries such as entrapment.
During a review of the facility's recent policy and procedure (P&P) titled Bed Safety and Bed Rails, last reviewed on 4/2024, the P&P indicated before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent:
a. The assessed medical needs that will be addressed with the use of bed rails;
b. The resident's risk from the use of bed rails and how these will be mitigated.
During a review of the facility provided information Bed Rail 1 (BR 1), last revised on 3/18/2021, the information indicated risk for serious injury. Individuals with physical limitations who cannot prevent themselves from rolling or climbing out the bed may require other means of safe positioning.
During a review of the facility's recent policy and procedure (P&P) titled Resident Assessments, last reviewed on 4/2024, the P&P indicated OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include:
B. Quarterly Assessment.
4. During a review of Resident 75's AR, the AR indicated the facility admitted the resident on 9/18/2024 with diagnoses including type 2 diabetes mellitus (DM 2, a condition that affects the way the body processes blood sugar [glucose]), generalized muscle weakness, and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
During a review of Resident 75's H&P, dated 9/27/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 75's MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up or clean up assistance with personal hygiene; supervision/touching assistance with eating, oral hygiene , rolling left and right, sitting to lying , lying to sitting on edge of bed; substantial/maximal assistance with toileting hygiene, and shower/bathing self; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 75's Order Summary Report, the Order Summary Report indicated a physician's order dated 9/17/2024:
[Non-restraint] Bilateral one quarter (1/4) SR locked when in bed as enabler for mobility during ADL performance and during repositioning. Informed consent obtained from the resident after explanation of risk and benefits. Monitor for presence, placement, and functionality every shift.
During a review of Resident 75's Fall Risk Assessments dated 9/18/2024, 9/23/2024, and 9/30/2024, the Fall Risk Assessments indicated the resident was a high risk for falls.
During a review of Resident 75's informed consent dated 9/17/2024, the informed consent indicated bilateral ¼ SR locked when in bed as enabler for mobility during ADL performance and during repositioning.
During a concurrent observation and interview on 10/9/2024 at 1:30 p.m. inside Resident 75's room with Certified Nursing Assistant 6 (CNA 6), observed Resident 75 lying in bed with bilateral ½ SR up and locked. CNA 6 stated Resident had history of falls since admission. CNA 6 stated Resident 75 uses the SR to assist in getting out of bed.
During a concurrent interview and record review on 10/11/2024 at 1:48 p.m., reviewed Resident 75's physician's orders, informed consent, restraint assessment, and manufacturers' guideline for Bed Rail 1 (BR 1) with Minimum Data Set Nurse 1 (MDSN 1). MDSN 1 verified Resident 75's SR is ½ SR instead of ¼ as indicated in the manufacturers' guideline and is considered a restraint. MDSN 1 stated the facility should have completed the restraint assessment, obtained a physician's order, and obtained an informed consent prior to use of bilateral upper ½ SR.
During an interview on 10/11/2024 at 3:30 p.m., the DON stated she was made aware that Resident 75's SR were ½ SR as indicated in the manufacturers' guideline. The DON stated use of ½ SR is considered a restraint as the SR restricts the resident's movement while in bed. The DON stated the facility should have completed the restraint or side rail assessment indicating the use of ½ SR to ensure appropriateness of the intervention, and the physician's order and informed consent should have indicated ½ SR.
During a review of the facility's P&P titled, Use of Restraint, last reviewed 4/2024, the P&P indicated:
Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.
The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint.
Prior to placing a resident on restraints, there shall be a pre-restraining assessment and review to determine the need for restraints.
Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted including:
a.
Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed;
d.
Placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising. Prior to placing a resident in restraints, shall be a pre-restraining assessment and review to determine the need for restraints.
Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (Sponsor). The order shall include the following:
a.
The specific reason for the restraint (as it relates to the resident's medical symptom);
b.
How the restraint will be used to benefit the resident's medical symptom; and
c. The type of restraints, and period of time for the use of the restraint.
Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use.
Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraints reduction, less restrictive methods of restraints, or total restraint elimination. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s).
During a review of the facility's P&P titled, Bed Safety and Bed Rails, last reviewed 4/2024, the P&P indicated the use of bed rails is prohibited unless the criteria for use of bed rails have been met including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The P&P indicated:
Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent.
The following information will be included in the consent:
a.
The assessed medical needs that will be addressed with the use of bed rails;
b.
The resident's risk from the use of bed rails and how these will be mitigated.
5. During a record review of Resident 107's AR, the AR indicated the facility originally admitted Resident 107 on 10/24/2023 and readmitted the resident on 10/31/2023 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area) affecting the left dominant side.
During a review of Resident 107's MDS, dated [DATE], the MDS indicated Resident 107 had difficulty understanding and making decisions, was dependent on facility staff for activities of daily living such as eating, hygiene, showering/bathing himself, toileting, dressing, and required maximal assistance with rolling left to right in bed. The MDS further indicated Resident 107 was not using bed rails or other forms of restraints.
During a review of Resident 107's H&P, dated 10/25/2023, the H&P indicated Resident 107 was forgetful, confused, and needs frequent reorientation to reality.
During a review of Resident 107's Order Summary Report, dated 10/31/2023, the Order Summary Report indicated Resident 107 was ordered bilateral quarter side rails locked when in bed as an enabler for, mobility during activity of daily living performance and during repositioning. The Order Summary Report further indicated informed consent was obtained from the resident after explaining of risks and benefits and to monitor for presence, placement, and functionality every shift.
During a review of Resident 107's Bedside Rail Entrapment Risk Evaluation, dated 8/7/2024, the Bedside Rail Entrapment Risk Evaluation indicated Resident 107 requires limited to total dependence with movement; is alert, oriented, able to follow commands and understand the use and purpose of bedside rail; requires supervised assist and cueing in using call alarms; and uses the bedside rail daily, less than 24 hours.
During an observation on 10/8/2024 at 9 a.m., inside Resident 107's room, Resident 107 was lying down in bed asleep with two quarter bed rails at both sides of the head of the bed.
During a concurrent interview and record review with the Minimum Data Set Director (MDSD) on 10/11/2024 at 8:44 a.m., Resident 107's medical record, current as of 10/11/2024, was reviewed. The MDSD stated the resident's bed rail consent was not in the physical medical record and electronic medical record. The MDSD stated the informed consent should be in the resident's active medical record. The MDSD stated it is important to have the informed consent in the active medical record so that the facility staff are aware that the resident consented to the use of bed rails. The MDSD further stated without the informed consent, there is a potential for improper communication between staff and the residents.
During an interview with the DON, on 10/11/2024 at 3:28 p.m., the DON stated there should be an informed consent in the resident's current medical record. The DON stated without an informed consent, the resident's rights to be informed of the treatments they are receiving would be violated.
During a review of the facility's P&P titled, Bed Safety and Bed Rails, last reviewed 4/2024, the P&P indicated the use of bed rails or side tails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation resident assessment, and informed consent.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medicati...
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Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of one sampled residents (Residents 70), investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and enoxaparin (a drug used to prevent blood clots), by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.
The deficient practices had the potential to result in adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and enoxaparin such as bruising, lipodystrophy (abnormal distribution of fat), and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).
Findings:
Cross Reference F658
During a review of Resident 70's admission Record (AR), the AR indicated the facility admitted the resident on 5/30/2024, with diagnoses including type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and surgical amputation (the surgical removal of all or part of a limb or extremity such as an arm, leg, foot, hand, to, or finger).
During a review of Resident 70's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) and hypoglycemic medications (drugs that help lower sugar levels).
During a review of Resident 70's Order Summary Report, the report indicated an order for:
5/3/2024 Enoxaparin sodium injection solution prefilled syringe 40 milligrams (mg, a unit of weight)/0.4 milliliters (ml, a unit of volume) (Enoxaparin Sodium). Inject 40 mg subcutaneously in the afternoon for deep vein thrombosis prophylaxis (dvt ppx, reduces the risk of developing deep vein thrombosis through medications, compression stockings, and devices).
8/16/2024 Insulin lispro injection solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale (a progressive increase in pre-meal or nighttime insulin doses): if 60-120= 0; less than (<) 70, may give 8 ounces (oz., a unit of weight) orange juice as tolerated; 125-150= 2 units (the standard amount required for a precise measure of activity); 151-200= 4 units; 201-250= 6 units; 251-300= 8 units; 301-350= 10 units; 351-400= 12 units; greater than (>) 400, call MD. Subcutaneously in the evening for DM before dinner.
10/3/2024 Lantus subcutaneous solution 100 unit/ml (Insulin Glargine). Inject 28 units subcutaneously at bedtime for DM.
During a review of Resident 70's Location of Administration Report for insulin and enoxaparin from 8/2024 to 10/2024, the report indicated insulin and enoxaparin was administered on:
Insulin Lispro Injection Solution 100 unit/ml
8/3/2024 at 5:08 p.m. on the Arm - right
8/4/2024 at 6:46 p.m. on the Arm - right
8/11/2024 at 5 p.m. on the Arm - left
8/12/2024 at 5:51 p.m. on the Arm - left
8/13/2024 at 5:06 p.m. on the Arm - left
8/15/2024 at 6:49 p.m. on the Arm - left
8/18/2024 at 4:07 p.m. on the Arm - left
8/19/2024 at 5:08 p.m. on the Abdomen - Left Upper Quadrant (LUQ)
8/20/2024 at 4:33 p.m. on the Abdomen - LUQ
9/3/2024 at 4:50 p.m. on the Arm - left
9/4/2024 at 5:03 p.m. on the Arm - left
9/23/2024 at 4:23 p.m. on the Arm - right
9/25/2024 at 6:13 p.m. on the Arm - right
Lantus Subcutaneous Solution 100 unit/ml
8/13/2024 at 9:31 p.m. on the Arm - right
8/14/2024 at 9:52 p.m. on the Arm - right
8/16/2024 at 8:37 p.m. on the Arm - right
8/20/2024 at 10:15 p.m. on the Arm - left
8/21/2024 at 8:28 p.m. on the Arm - left
Enoxaparin Sodium Injection Solution Prefilled Syringe 40 mg/0.4 ml
9/6/2024 at 7:53 p.m. on the Abdomen - LUQ
9/7/2024 at 11:01 p.m. on the Abdomen - LUQ
9/12/2024 at 5:46 p.m. on the Abdomen - Right Lower Quadrant (RLQ)
9/13/2024 at 6:26 p.m. on the Abdomen - RLQ
9/20/2024 at 4:37 p.m. on the Abdomen - Left Lower Quadrant (LLQ)
9/21/2024 at 4:45 p.m. on the Abdomen - LLQ
During a concurrent interview and record review, on 10/10/2024, at 10:51 a.m., with Registered Nurse 1 (RN 1), Resident 70's Order Summary Report and Location of Administration Report for insulin and enoxaparin from 8/2024 to 10/2024 were reviewed. RN 1 stated there was an order for Enoxaparin sodium injection solution prefilled syringe 40 mg/0.4 ml, Insulin Lispro Injection Solution 100 unit/ml, and Lantus Subcutaneous Solution 100 unit/ml. RN 1 stated there were multiple instances that the insulin and enoxaparin subcutaneous administration was not rotated during the period 8/2024 to 10/2024. RN 1 stated the licensed staff should rotate the insulin and enoxaparin administration sites to prevent bruising and lipodystrophy. RN 1 stated not rotating insulin and enoxaparin administration sites were considered as medication errors.
During a concurrent interview and record review, on 10/11/2024, at 2:10 p.m., with the Director of Nursing (DON), Resident 70's Order Summary Report and Location of Administration Report for insulin and enoxaparin from 8/2024 to 10/2024 were reviewed. The DON stated there were multiple instances that insulin and enoxaparin subcutaneous administration were not rotated during 8/2024 to 10/2024. The DON stated the licensed nurses should rotate enoxaparin and insulin administration sites to prevent muscle shrinking and bruising of the skin. The DON stated not rotating insulin and enoxaparin administration sites were considered as medication errors.
During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services.
During a review of the facility's recent policy and procedure (P&P) titled Insulin Administration, last reviewed on 4/2024, the P&P indicated to select an injection site:
a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel.
b. Injection sites should be rotated preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility provided information sheet How to use your Lantus Solostar pen, copyright 2022, the sheet indicated to rotate your injection sites with each dose to reduce your risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff:
a.
Failed to maintain safety and ...
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Based on observation, interview, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff:
a.
Failed to maintain safety and sanitation in the kitchen when:
1.
There were cracked racks in the walk-in freezer.
2.
Mixer had food debris and residue.
3.
Food preparation roof rack had food splatters and food buildup.
4.
Chopping boards had scratches and stains.
b.
Failed to perform hand hygiene after picking up a potato on the floor then continued washing the other batch of potatoes in the preparation sink.
c.
Failed to follow menus for lunch on 11/20/2024 when [NAME] 1 cooked green peas with onions instead of seas greens without a Registered Dietitian approval.
d.
Failed to serve breads without hard crust on soft mechanical diets (diet that are soft and chopped).
e.
Failed to update the allergy list posted in the kitchen and in the electric medical record for Resident's 76.
This failure had a potential to result in inaccurate food texture, ineffective therapeutic diets, difficulty swallowing, chewing, eating, allergic reactions and foodborne illnesses (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) of 137 of 139 facility residents getting food from the kitchen.
Findings:
a. (1) During a concurrent observation and interview on 11/20/2024 at 8:24 a.m. in the walk-in freezer with Assistant Dietary Supervisor (ADS), four (4) of six (6) blue racks had chips and cracks. ADS stated they replaced the racks in the walk-in refrigerator, but he was not aware if they replaced the racks on the walk-in freezer yet.
(2) During a concurrent observation and interview on 11/20/2024 at 8:33 a.m. of the mixer with ADS, the mixer was covered in plastic and the internal parts of the mixer had dried-up food residues. ADS stated the staff last used the mixer was yesterday afternoon and it was supposed to be cleaned every after use because the food residue and debris could fall into the food causing cross-contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another). ADS stated cross-contamination could cause residents to get sick and get ill.
(3) During an observation on 11/20/2024 at 8:53 a.m. of the preparation area rack with ADS, the roof rack had food splatters and buildup. ADS stated the preparation roof rack should be cleaned every shift to prevent cross-contamination.
(4) During a concurrent observation and interview on 11/20/2024 at 8:55 a.m. of the chopping boards with ADS, the white, brown, and green chopping boards had scratches and the blue chopping board had food splatter. ADS stated the chopping boards were replaced with new ones, but he did not notice the white and brown chopping board had scratches too, hence he would be replacing those too. ADS stated the blue chopping board with food splatter stains was not acceptable due to cross-contamination to food.
During an interview on 11/20/2024 at 8:59 a.m. with ADS, ADS stated the racks and chopping boards that had chips and scratches could get on the food and would not be safe for the residents because there could be bacteria in them.
During a review of the facility's policy and procedures (P&P) titled Sanitation, reviewed 4/2024, the P&P indicated Policy: The Food and Nutrition Services (FNS) Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. Procedures:
The FNS Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques.
The FNS Director is responsible for instructing Food and Nutrition
know how to operate and clean equipment in his specific work area.
The FNS Director will write the cleaning schedule in which he designates by job title and/or employee who is to do the cleaning task.
All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas.
Kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixture, and the hod over stove, which will be cleaned by the maintenance staff.
Separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized.
b.
During a concurrent observation and interview on 11/20/2024 at 8:44 a.m. of the food preparation with ADS, ADS stated [NAME] 1 picked the potatoes up from the floor then went back to washing the potatoes without washing her (Cook 1 hands and changing her gloves. ADS stated [NAME] 1 missed those steps and it was important for [NAME] 1 to wash her hands for sanitation purposes to get any bacteria out of her hand. ADS stated dirt could transfer bacteria to food and residents could get sick due to bacteria transfer.
During a review of the facility's P&P titled Handwashing/Hand Hygiene, dated 10/2023, the P&P indicated, Policy statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. (1) all personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. (2) All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.
During a review of the facility's P&P titled Handwashing Procedures, reviewed 4/2024, the P&P indicated Handwashing is important to prevent the spread of infection. When hands needed to be washed: (4) Before and after handling foods with hands (cutting, peeling, mixing, etc.)
During a review of the facility's P&P titled Sanitation, reviewed 4/2024, the P&P indicated, All Food and Nutrition Services staff shall know the proper handwashing technique. The FNS Director is responsible for proper training of this.
c.
During a review of the facility's daily spreadsheet titled Cycle 4 2024, dated 11/20/2024, the spreadsheet indicated residents on regular diet (diet with no restrictions) would get the following food items for lunch:
Seasoned beans/ham 2/3 cups ([c] a household measurement)
Skillet fried potatoes ½ c.
Seas greens ½ c
Corn bread/margarine 1 each
Apple pie mousse ½ c
Beverage 8 ounces ([oz] unit of measurement)
During an observation on 11/20/2024 at 11:37 a.m. of trayline (area where food trays are assembled), peas with onions was on the steamtable and there were no seas greens prepared.
During a concurrent observation and interview on 11/20/2024 at 1:25 p.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) with Registered Dietitian 2 (RD 2), [NAME] 1 and ADS, RD 2 stated soft mechanical would get chopped seas greens. RD 2 stated the ingredients called for variety of greens and maybe substituted with collard greens, turnip, spinach, mustard, kale, or chard. RD 2 stated green peas was not an appropriate substitute for green seas and she was not aware of it. ADS stated spinach was available, but they did not use it. [NAME] 1 stated she has always read the recipe and followed it and thought the recipe for green seas called for green peas. RD 2 stated staff must follow the recipes always. RD 2 stated residents might not eat the food causing weight loss as a potential outcome. ADS stated residents might not be happy with the substitute and may not eat it causing weight loss.
During an interview on 11/20/2024 at 2:25 p.m. with RD 2, RD 2 stated she must retrain the staff for proper substitution of food because improper substitution would not provide enough calories leading to weight loss due to inadequate intake.
During a review of the P&P titled Menu Planning, dated 4/2024, the P&P indicated, the menu service, which provides seasonal menus with corresponding recipes. All daily menu changes, with the reason for the change, are to be noted on the back of the kitchen spreadsheet or a logbook may be kept. Only the facility Registered Dietitian, FNS director or cook, can make these changes. Only the facility Registered Dietitian or FNS director can make permanent changes. The facility Registered Dietitian is to sign and date spreadsheets when changes are made. Menu changes are also be noted on menus on the consumers board and any other menus which may be noted. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation.
During a review of the facility's Job Description titled Cook, signed by [NAME] 1 and DS, undated, the Job Description indicated, The [NAME] prepares palatable, nutritionally sound meals consistent with departmental policies and procedures consistent with county, state and federal laws and regulations as applicable, that meet daily nutritional and special dietary needs of each resident. Job Functions:
Follow recipes and prepares foods that correspond to menu cycles and recipes prepared by Dietitian.
Frequently clean food service work areas as food preparation and service are done, and between tasks.
Able to understand and follow written and verbal directions including menus, tray tickets, substitution lists and labels. Able to effectively communicate with staff members and residents through verbal and/or written means.
During a review of the facility's competency checklist titled Skills Evaluation dated and signed by [NAME] 1 and DS on 10/14/2024, the competency checklist indicated, [NAME] 1 demonstrated and met competencies for handwashing, reading menus, and spreadsheets
d.
During a review of the facility's daily spreadsheet titled Cycle 4 2024, dated 11/20/2024, the spreadsheet indicated residents on soft mechanical (diet that are soft and chopped) would get the following food items for lunch:
Ground seasoned beans/ham 2/3 c.
Chopped skillet fried potatoes ½ c.
Chopped Seas greens ½ c.
Corn bread/margarine 1 each
Apple pie mousse ½ c
Beverage 8 ounces
During a concurrent observation and interview on 11/20/2024 at 1:25 p.m. of the test tray with RD 2, RD 2 stated residents received hard crust of corn bread after testing the tray and it should not be. RD 2 stated soft mechanical diet was used for residents with missing teeth and difficulty swallowing. RD stated if food was not in the right consistency residents might not eat it causing weight loss or residents could choke.
During a review of the facility's P&P titled Menu Planning, reviewed 4/2024, the P&P indicated Procedures: The facility's diet manual and diet ordered by the physician should mirror the nutritional care provided by the facility.
During a review of the facility's Diet Manual titled Mechanical Soft (Ground), dated 4/2024, the P&P indicated Intended use: To provide a nutritionally adequate that requires a reduced amount of mastication. Normally, this order is for residents who have limited chewing abilities and intact swallowing ability.
During a review of the facility's Diet Manual titled Nutritional Management of Dysphagia (difficulty swallowing) - Dysphagia Mechanical, reviewed 4/2020, the Diet Manual indicated This diet consists of foods that are moist, mechanically altered, or easily mashed. This is necessary in order to form a cohesive bolus requiring little chewing. Food must not be sticky or bulky increasing the risk of airway obstruction. General Principles: Food served should form a cohesive bolus and not fall apart when swallowed. Beware of foods that crumble like corn bread, cake, etc. or are dry such as rice, meat without gravy, some vegetables and fruits, or long stringy pasta like spaghetti. Dry food should be softened with fluid or gravy, ground meat moistened with gravy, corn bread pureed or soaked with milk. [NAME] and vegetables that have a hull such as peas or corn should be pureed.
e. During a review of Resident 76's admission Record, the admission Record indicated the facility initially admitted Resident 76 on 11/11/2021 and readmitted the resident on 12/18/2021 with diagnoses including essential hypertension (high blood pressure), type two (2) diabetes (a long-term condition that occurs when body does not produce insulin (hormone that lowers the level of glucose [sugar] in the blood) resulting to high levels of blood sugar in the body) and morbid obesity (a chronic disease that is characterized by a body mass index (BMI - a medical screening tool that measures the ratio of your height to your weight to estimate the amount of body fat you have) of 40 or higher).
During a review of Resident 76's Minimum Data Sheet (MDS, a resident assessment tool), dated 8/16/2024, the MDS indicated Resident 76's cognition (a mental process that take place in the brain, including thinking, attention, language, learning, memory, and perception) was intact. The MDS indicated Resident 76 needed set-up and clean-up assistance (helper sets up and cleans up, resident completes the activity) when eating.
During a review of Resident 76's Physician diet order, dated 2/27/2024, Resident 76's Physician diet order indicated Resident 76's diet was on consistent carbohydrate diet ([CCHO] a diet that had the same amount of carbohydrates in each meal to lower blood sugar levels), mechanical soft chopped texture, regular thin consistency, no added salt ([NAS] diet with no salt packets on the tray), pureed vegetables, for no pork, beef and banana.
During a review of the facility log titled Allergy list, dated 11/20/2024 posted in the kitchen, the allergy list indicated, Resident 76 was allergic to artificial flavoring, banana, beef, and pork.
During an observation on 11/20/2024 at 12:45 p.m. in the trayline area, Dietary Aide 1 (DA 1) announced to staff, Resident 76 was allergic to banana, beef, guava, pork, artificial flavoring agent, banana, and pork.
During an observation on 11/20/2024 at 12:48 p.m. of the Resident 76's diet ticket, artificial strawberry flavor was not listed in the allergy section of the meal ticket instead it was listed under resident's dislike section.
During a concurrent observation and interview on 11/20/2024 at 1:02 p.m. with Resident 76, Resident 76's band indicated she was allergic to strawberry artificial flavoring and color number five (5). Resident 76 stated she was allergic to artificial flavoring for strawberries only and she itches as an allergic reaction. Resident 76 stated she did not tolerate any strawberry flavoring in Jello or ice cream. Resident 76 she was also allergic to bananas, papaya, guava, and she had redness of the mouth and coughing blood as an allergic reaction if she consumed these products. Resident 76 stated they served her bananas and strawberry in the past in a form of banana pudding and strawberry ice cream.
During a concurrent interview and record review on 11/20/2024 at 2:28 p.m. with RD 2, Resident 76's medical records and allergy list were reviewed. Resident 76's medical record indicated Resident 76 was allergic to artificial flavoring agent, beef, banana, guava, pork, and papaya. RD 2 stated the allergy list did not match Resident 76's electronic record and it should match. RD 2 stated Resident 76's diet ticket did not indicate strawberry artificial flavoring in the allergy section. RD 2 stated she has not spoken to Resident 76 and RD 1 nutritional assessment on 10/9/2024 indicated Resident 76 was allergic to artificial flavoring agent, guava, and papaya. RD 2 she needed to talk to Resident 76 to clarify the food allergies.
During an interview on 11/20/2024 at 3:00 p.m. with RD 2, RD 2 stated resident was allergic to strawberry artificial flavoring, banana, pork, guava, passion fruit and red dye. RD 2 stated it was important to update resident's food allergies to prevent resident's allergic reactions that could cause change of conditions to residents and death.
During a review of the facility's P&P titled Food Allergies and Intolerances, reviewed on 4/2024, the P&&P indicated Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen. Interventions:
1.
Residents are assessed for a history of food allergies and intolerances upon admission and as part of comprehensive assessment.
2.
All resident reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident's care plan.
3.
Meals for residents with severe food allergies are specially prepared so that cross-contamination with allergens does not occur.
During a review of the facility's Job Description titled Dietary Aide signed by ADS on 3/25/2021, the Job Description indicated, The primary purpose of this position is to provide assistance in all dietary functions as directed an in accordance with the established dietary policies and procedures. Duties and Responsibilities:
Ensures that dietary procedures are followed in accordance with established policies, production sheets and recipes, including the use of adaptive devices per instructions.
Assist in checking dietary trays before distribution to ensure correct meal is going to each resident.
Follow cleaning schedule as assigned, including workstations, refrigerators/freezers, stove, steam table, sink, equipment, etc.
During a review of the facility's competency checklist titled Skills Evaluation signed by ADS and DS, undated, the competency checklist indicated, ADS met and demonstrated competencies on food allergies, use of meal tickets, allergy reference log and use of equipment and cleaning, sanitizing equipment including equipment competency review.
During a review of the facility's Job Description titled Food and Nutrition Services Director, dated and signed by Dietary Supervisor (DS) on 9/16/2024, the Job Description indicated The primary responsibility of your job position is planning, organizing, developing, and directing the overall operation of the Food Service Department following the current federal, state, and local standards, guidelines, and regulations that govern long term care and assisted living facilities. You are entrusted to assure the quality nutritional services are provided on a daily basis and that the Food Service Department is maintained in a clean and sanitary manner. Skills and Knowledge:
Must be knowledgeable of food services and procedures as well as the laws, regulations, and guidelines governing food services functions in nursing care facilities.
Must maintain the care and use of supplies, equipment, and maintain the appearance of food service area.
Must perform regular inspection of food services area for sanitation, order, safety, and proper performance of assigned duties.
During a review of the facility's Job Description dated Registered Dietician undated, the Job Description indicated, Position Summary: Responsible for the nutritional care of the residents in accordance with the current applicable federal, state, and local standards, guidelines and regulations, established company policies and procedures, and in coordination with the Director of Dietary Services to ensure that quality food service and nutritional care appropriate to each resident is provided at all times. Duties and Responsibilities:
Reviews the dietary requirements of each resident when admitted to facility and as may be required and assists the attending physician in planning resident's prescribed diet plan.
Ensures that a current, legible diet card with resident's name, room number, diet order, food preferences and any other pertinent information is available for all residents who receive meals, and is updated as needed.
Performs documentation duties as required and in accordance with company charting and documentation policies and procedures and government regulations. Ensure documentation is accurate, informative of descriptive of resident's condition, care provided and resident's response.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of the facility's daily spreadsheet titled Therapeutic Spreadsheet Cycle 4, dated 10/8/2024, the spreadsheet ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of the facility's daily spreadsheet titled Therapeutic Spreadsheet Cycle 4, dated 10/8/2024, the spreadsheet indicated residents on regular portions would get 3 ounces (oz, unit of measurement) of pork and 5 oz of pork for the large portion diets.
During an observation on 10/8/2024 at 11:47 a.m. at the trayline area, the sliced pork was not consistent in sizes.
During a concurrent observation and interview on 10/8/2024 at 12:44 p.m. with the Dietary Supervisor (DS) and the Assistant Dietary Supervisor (ADS), the large portion diets received two (2) slices of pork. The DS stated large portion diets should receive five (5) oz of pork and regular portion diets should receive three (3) oz of pork. The DS stated large portion diets was used for residents with weight loss and for large-framed residents who would feel hungry and needed more portions and nutrients. The DS stated staff should give 3 pieces (pcs) of meat of large portion diet. The ADS stated they do not have any weighing scale in the kitchen. The DS stated they might have a weighing scale in the office. The DS stated weighing scale should be used to determine the actual portion sizes of pork for accuracy. The DS stated residents could have weight loss if proper portion size were not served to them.
During an interview on 10/8/2024 at 12:47 p.m. with [NAME] 1, the ADS, and the DS, [NAME] 1 stated regular portion diets would get 2 pcs of pork and large portion diets would get 3 pcs of pork. [NAME] 1 sated the pork came in as a whole portion and she sliced it. [NAME] 1 stated she estimated the sizes of meats while cutting it and did not use a weighing scale today. [NAME] 1 stated they used a weighing scale in the past that was why she knew 2 pcs is 3 oz and 3 pcs is 5 oz. The ADS stated estimating meat portions without weighing the meat was an okay practice because they already weighed the meats in the past. The ADS stated weight loss would be the potential outcome for not following portion sizes for residents on large portion diets and residents on other diets would not get sufficient food.
During an interview with the Director of Nursing (DON), on 10/11/2024, at 3:28 p.m., the DON stated if residents do not receive the specified amount of food according to the menu, it can potentially impact the weight of the resident, by either gaining or losing weight. The DON further stated if residents are not served the right amount, the residents can feel hungry.
During a review of the facility's recipe titled BBQ Pork (P) #2 not dated, the BBQ Pork recipe indicated suggested portion 3 oz.
During a review of the facility's P&P titled Portion Sizes, dated 4/2024, the P&P indicated, Various portion sizes of food served will be available to better meet the needs of the residents. Procedure: The small and large portion servings will be served as printed on the cook's spreadsheet for every meal. ½ size portions are to be given to those residents who request smaller portions than the small portion diet provides. The food server is to give the ½ size portion of the regular diet for the food on the main plate-entrée, vegetable, and starch.
b. During a concurrent interview and record review on 10/10/2024 at 2:34 p.m. with [NAME] 1 and the RD with the Interpreter's (translating [NAME] 1's language via phone) assistance, the facility's undated recipe titled Baked Beans #2 was reviewed. Baked Beans #2 had an ingredient of pork and beans, light brown sugar, chopped onions, and mustard. [NAME] 1 stated she did not use the pork and beans and used pinto beans for the baked bean dish. [NAME] 1 stated she used the ketchup, light brown sugar, and yellow mustard but did not use chopped onions. [NAME] 1 stated she used onion powder instead of chopped onions because she did not like the flavor of the onion but likes the onion powder when making the baked beans. [NAME] 1 stated she used onion powder and added one spoon to the baked beans using estimation on how the food would taste as it (recipe) did not indicate the amounts. [NAME] 1 stated she said onion to ADS who was interpreting in [NAME] 1's language during the interview on 10/8/2024 and never mentioned onion powder because she (Cook 1) forgot to say powder. [NAME] 1 stated raw onions were available in the kitchen on 10/8/2024. The RD stated the staff (unable to recall who) notified her of the substitution of onions to onion powder after the Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) was called. he RD stated she did not agree with the substitution of using onion powder for onions based on how [NAME] 1 felt about the flavor as it was not a standard of practice. The RD stated the onion powder could have more ingredients that would contain more food allergens. The RD stated the recipe must be followed to ensure residents got the nutrients that they needed and so they could be aware of the ingredients for food allergies.
During a review of the facility's P&P titled Food Preparation dated 4/2024, the P&P indicated Procedure: (1) The facility will use approved recipes, standardized to meet the resident census. (2) Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. (3) Prepared food will be sampled.
c. During a review of Resident 74's admission Record, the admission Record indicated the facility admitted the resident on 9/11/2021 and most recently readmitted the resident on 5/18/2024 with diagnoses that included diseases of the liver (organ that removes toxins from the body's blood supply), displaced comminuted fracture (a bone breaks into multiple pieces) of the shaft of the right femur (thigh bone), type two DM, and anemia (a condition where the body does not have enough healthy red blood cells).
During a review of Resident 74's MDS, dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS indicated the resident was dependent on staff for toileting, bathing, dressing, and required substantial assistance with rolling left and right. The MDS further indicated the resident required set up assistance with eating.
During a review of Resident 74's Physician Order Summary Report, the report indicated an order for the following:
- Consistent carbohydrate diet, regular texture, regular/thin consistency, give large portion of protein, eight ounces (a unit of measurement) of water and sugar free jello at all meals, dated 9/5/2024.
During an interview on 10/8/2024 at 9:50 a.m., Resident 74 lay in bed and stated if something is on the menu, it is usually substituted or missing, and they forget to bring the food she asks for. Resident 74 stated the kitchen has been doing this for quite a while.
During a review of the facility Noon Meal Menu for October 2024, the menu indicated on 10/9/2024 the menu would include the following:
-Country Fried Steak
-Mashed potatoes with gravy
-Seas peas with onions
-Roll with margarine
-Boston cream pie
-Beverage
During an observation and interview on 10/9/2024 at 12:20 p.m., Resident 74 sat in bed eating the noon meal. Resident 74 stated she was not served gravy on the mash potatoes. Resident 74 stated they (the facility) always forget something.
During a concurrent interview and observation on 10/9/2024 at 12:25 p.m., Certified Nursing Assistant 4 (CNA 4) stated the resident was not served gravy on her mashed potatoes and she did not know why.
During an interview on 10/9/2024 at 12:58 p.m. with the Assistant Dietary Supervisor (ADS), the ADS stated it was an oversite that gravy was not provided on Resident 74's mashed potatoes, but it should have been included.
During an interview on 10/9/2024 at 1 p.m. with the Dietary Supervisor (DS), the DS stated Resident 74 should have been served gravy on her mashed potatoes. The DS stated when gravy was on the menu and not served to the resident it could lead to resident disappointment. The DS stated when residents are disappointed, they may not eat the food.
During an interview on 10/11/2024 at 8:58 a.m. with the DON, the DON stated it was important to follow the facility menu and serve what is indicated. The DON stated resident's get the menu before meals and they know what will be served and they can request a substitution if they do not like what is being served. The DON stated when resident's feel something is wrong it can have a psychosocial impact that could potentially lead to them refusing food and impacting their diet. The DON stated when food is refused it could potentially result in unintended weight loss in residents. The DON stated the facility process was not followed when the kitchen did not follow the posted menu.
During a review of the facility P&P titled, Menu Planning, last reviewed on 4/2024, the P&P indicated menus with corresponding recipes will be provided to the facility at least two weeks in advance. All daily menu changes, with the reason for the change, are to be noted and only the RD or cook can make these changes. Menu changes should also be noted on menus on the consumers board and any other menus which may be posted. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines. Physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences.
During a review of the facility P&P titled, Tray Identification, last reviewed 4/2024, the P&P indicated the Food Services Manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas.
During a review of the facility P&P titled Food Preparation last reviewed 4/2024, the P&P indicated the procedure includes that the facility will use approved recipes, standardized to meet the resident census. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide.
Based on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 138 of 139 residents on regular texture diets (diet with no restrictions) when:
a.
The staff served pork BBQ without weighing portion sizes on all the diets, including Resident 105.
b.
The cook did not follow the recipe of baked beans for lunch service on 10/8/2024.
c.
The facility failed to follow the lunch menu on 10/9/2024 by omitting gravy from the mashed potatoes for Resident 74.
These deficient practices had the potential to cause difficulty in eating, chewing, and swallowing to the residents, cause resident dissatisfaction, and decrease food and nutrient intake resulting to unintended (not done on purpose) weight loss.
Findings:
a.
During a review of Resident 105's admission Record, the admission Record indicated the facility admitted Resident 105 on 9/17/2024 with diagnoses including type two diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control).
During a review of Resident 105's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/23/2024, the MDS indicated Resident 105 had difficulty understanding and making decisions and was able to eat with set-up assistance.
During a review of Resident 105's History and Physical (H&P), dated 9/18/2024, the H&P indicated Resident 105 had the capacity to understand and make decisions.
During a review of Resident 105's Order Summary Report, dated 9/17/2024, the Order Summary Report indicated Resident 105's diet was a consistent carbohydrate (a therapeutic diet that helps control blood sugar levels), no added salt diet with regular texture, and regular or thin liquid consistency.
During a review of Resident 105's Care Plan, dated 9/28/2024, the Care Plan indicated Resident 105 has nutritional problems or potential nutritional problems with interventions including to provide and serve diet as ordered.
During an interview with Resident 105, on 10/8/2024, at 9:36 a.m., Resident 105 stated the portion sizes he is served are small and he is still hungry after eating.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
During a review of the facility's daily spreadsheet titled Therapeutic Spreadsheet Cycle 4, dated 10/10/2024, the spreadsheet indicated residents on regular diet (no food restriction) would include th...
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During a review of the facility's daily spreadsheet titled Therapeutic Spreadsheet Cycle 4, dated 10/10/2024, the spreadsheet indicated residents on regular diet (no food restriction) would include the following foods in the tray:
Apple juice 4 ounces (oz, a unit of measurement
Cold cereal 1 serving
Sausage patty 2 each
Country gravy 1 oz
Biscuit 1 each
Coffee 8 oz
Milk 8 oz
During a concurrent observation and interview on 10/10/2024 at 8:03 a.m., of the test tray (a process of tasting, checking food temperatures, and evaluating the quality of food) with the Dietary Supervisor (DS), the test tray temperatures were as follows:
Sausage patty 113°F
Biscuit with gravy 108°F
Milk 49°F
Juice 45°F
The DS stated she heard there was a resident who had issues with food temperatures. The DS stated that on 10/10/2024, food temperatures for juice and milk were higher than usual and patty sausage and country gravy were lower in temperature than usual. The DS stated residents would be disappointed if the temperatures of the food were not acceptable and they would not eat the food resulting to weight loss as a potential outcome.
During an interview with the Director of Nursing (DON), on 10/11/2024, at 3:28 p.m., the DON stated if food was not served at the appropriate temperatures, it could alter the taste of the food and the residents could lose their appetite. The DON further stated if the residents do not eat their food, there was a potential for the residents to lose weight.
During a review of the facility's policy and procedure (P&P) titled, Menu Planning, last reviewed 4/2024, the P&P indicated menus provide a variety of foods in adequate amount each meal and standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation.
During a review of the facility's P&P titled Food Preparation, dated 4/2024, the P&P indicated Food shall be prepared by methods that conserve nutritive value, flavor and appearance. (2) Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. (7) Hold foods prior to service for a short time as practical. A maximum 1 hour holding time is recommended. Hot foods should be held prior to service at 140°F or above and cold foods at 41°F or below. Keep foods covered during holding.
During a review of the facility's P&P titled Food Preparation and Service, dated 4/2024, the P&P indicated Food Distribution and Service (1) Proper food and cold temperatures are maintained during food distribution and service.
Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperatures when breakfast food temperatures in Station Four (4) had the following temperatures:
-
Sausage patty 113 degrees Fahrenheit (°F, a degree of temperature)
-
Biscuit with gravy 108°F
-
Milk 49°F
-
Juice 45°F
This deficient practice placed 138 of 140 facility residents, including Resident 19, on regular consistency texture (texture with no restriction) and texture modified diets at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.
Findings:
During a review of Resident 19's admission Record, the admission Record indicated the facility originally admitted Resident 19 on 7/13/2010 and readmitted the resident on 12/23/2023 with diagnoses including end stage renal disease (ESRD, irreversible kidney failure), dependence on renal dialysis (also known as hemodialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and generalized muscle weakness. The admission Record further indicated Resident 19's room was in Station 4.
During a review of Resident 19's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/3/2024, the MDS indicated Resident 19 was able to understand and make decisions, was independent or required setup to moderate assistance with activities of daily living including eating, hygiene, showering/bathing herself, dressing, toileting, and surface-to-surface transfers, and received hemodialysis treatments as a resident.
During a review of Resident 19's History and Physical (H&P), dated 12/24/2023, the H&P indicated Resident 19 has the capacity to understand and make decisions.
During a review of Resident 19's Order Summary Report, dated 9/3/2024, the Order Summary Report indicated Resident 19 was ordered a consistent carbohydrate renal diet (a therapeutic diet that helps control blood sugar levels and maintains fluid level, electrolytes, and minerals balanced) with regular texture and consistency.
During an interview with Resident 19, on 10/8/2024, at 9:44 a.m., Resident 19 stated the hot plates in the kitchen do not keep the food warm and when she receives breakfast, it is served cold. Resident 19 further stated when her food is served cold, it makes her want to eat less.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on soft mechanical-chopped diet (diet consisted of fo...
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Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on soft mechanical-chopped diet (diet consisted of food that are chopped half inches ([in] a unit of measurement) and soft foods) received whole hard biscuit on the plate for lunch service.
This deficient practice had the potential to cause coughing, choking (to keep from breathing the normal way) and death for 17 of 17 residents on soft mechanical chopped diet.
Findings:
a. During a review of Resident 135's admission Record, the admission record indicated the facility initially admitted Resident 135 on 10/1/2024 with diagnoses including, but not limited to chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems), chronic viral hepatitis C (long term liver inflammation and infection), and essential hypertension (high blood pressure).
During a review of Resident 135's Minimum Data Sheet (MDS, a standard assessment tool that measures health status), dated 10/5/2024, the MDS indicated, Resident 135's cognition (a mental process that take place in the brain, including thinking, attention, language, learning, memory, and perception) was severely impaired. The MDS indicated Resident 135 needed set-up and clean-up assistance (helper sets up and cleans up, resident completes the activity) when eating.
During a review of Resident 135's Physician diet order, dated 10/1/2024, Resident 135's Physician diet order indicated Resident 135 diet was Regular diet Mechanical soft- chopped texture (a diet with foods that were modified in texture to soft, chopped or ground consistency), regular thin consistency.
During a review of the facility's daily spreadsheet titled Therapeutic Spreadsheet Cycle 4, dated 10/8/2024, the spreadsheet indicated residents on mechanical soft would include the following foods in the tray:
Ground barbecue pork (BBQ) 3 ounces (oz, a unit of measurement)
Baked beans ½ cup (c, a household measurement)
Finely chopped creamy coleslaw ½ c
Biscuit 1 piece
Peach cobbler 1 square
Beverage 8 oz
During an observation on 10/8/2024 at 12:34 a.m. of Resident's 135 tray, Resident 135 received chopped pork with BBQ sauce, beans in a bowl with pieces of onions, biscuit, clear broth, cake, and juice.
During a concurrent observation and interview on 10/8/2024 at 12:35 p.m. with Resident 135, Resident 135 stated the biscuit was too hard. Resident 135 threw the biscuit on the tray, showed how hard it was as he could not even break it with his hand. Resident 135 stated he does not always get hard breads but most of the time he did. Resident 135 stated he could not tolerate and eat the hard breads because he did not have upper and lower teeth.
During an observation on 10/8/2024 at 12:43 p.m. in trayline (an area where foods were assembled), Resident 101 received a whole biscuit. Resident 101's meal ticket indicated diet Soft mechanical chopped diet, consistent carbohydrate (CCHO, diet with the same amount of carbohydrates in each meal and avoided simple sugar in the diet), no added salt (NAS, no salt packets on the trays).
During an interview on 10/8/2024 at 1:01 p.m. with the Assistant Dietary Supervisor (ADS), ADS stated soft mechanical diets was used for residents with not teeth and could not chew. The ADS stated soft mechanical diet could have biscuit after reviewing the menu spreadsheets. The ADS stated they were not supposed to give soft mechanical diets hard breads. The ADS stated he did not try the biscuit for lunch.
During an interview on 10/9/2024 at 10:11 a.m. with Registered Dietitian (RD), the RD stated she provided oversight in the kitchen. The RD stated they used a combination of National Dysphagia Diet (NDD, set of guidelines on modifying food and drink textures for people with chewing and/or swallowing difficulties) and International Dysphagia Diet Standardization Initiatives (IDDSI, the current evidence-based guidelines on modifying food and drink textures for people with chewing and/or swallowing difficulties) guidelines. The RD stated soft mechanical diet was a textured modified using soft foods. The RD stated bread on the soft mechanical diet was a quarter (1/4) inch (in., a unit of measurement) in size and bread edges must be removed because it would be too hard. The RD stated it would not be appropriate to give hard breads on soft mechanical diets as residents could choke, cough and would not tolerate it. The RD stated hard breads would delay residents from eating leading to weight loss as a potential outcome if not addressed.
During a review of the facility's Diet Manual titled Mechanical Soft, dated 4/2024, the mechanical soft diet manual indicated Intended use: to provide a nutritionally adequate diet that requires a reduced amount for mastication. Normally this order is for residents who have limited chewing ability and intact swallowing ability. Definition of menu terms: chopped: ¼ inches to ½ in pieces.
During a review of the facility's Diet Manual titled Regular Mechanical Soft Diet, dated 2020, indicated Description: The Mechanical Soft diet is designed for residents who experience chewing or swallowing limitations. The regular diet is modified in texture to a soft, chopped or ground consistency as per foods below. Food avoided included breads with hard crust.
During a review of the facility's recipe titled Biscuit (F) not dated, the Biscuit recipe indicated, ingredient: biscuit dough, frozen 2.2 oz. Note: it is recommended to serve puree bread/biscuit or gelled bread for dysphagia soft and bite-sized level 6 diets. Chop regular portions. Make sure all particles are more than 15mmx15mm (1/2 in.) in size.
During a review of the facility's Policies and Procedures (P&P) titled Food Production, dated 4/2024, the Food Production P&P indicated The preparation of food will be done following standard food handling techniques. Standardized recipes, quantity cookbooks, safe handling and an approved diet manual will be made available to assist Food and Nutrition Services employees.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:
a.
Two (2) vents had dust buildup...
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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:
a.
Two (2) vents had dust buildup in the walk-in refrigerator.
b.
Five (5) of six (6) blue racks were chipped, cracked and rusted in the walk-in refrigerator and one (1) of 6 racks was chipped in the walk-in freezer.
c.
There was an ice buildup in the walk-in freezer, curtains and door.
d.
Cook 1 was wearing a gold bracelet during food preparation.
e.
Internal parts of the mixer had dry food residue.
f.
Roof rack had dried food splatters and buildup.
g.
Chopping boards had scratches and were sticky to touch.
These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 138 of 139 medically compromised residents who received food and ice from the kitchen.
Findings:
a. During an observation on 10/8/2024 at 8:09 a.m. inside the walk-in refrigerator, the 2 vents had dust buildup.
During a concurrent observation and interview on 10/8/2024 at 8:22 a.m. with the Dietary Supervisor (DS), the DS stated the vents was cleaned yesterday during the delivery of food. The DS touched the vent and stated it looked like the vent had dust buildup. The DS stated the dusts could go in the food and food could be contaminated that would cause residents to get sick of foodborne illnesses.
During a review of facility's Policies and Procedures (P&P) titled Sanitation, date 4/2024, the Sanitation P&P indicated, POLICY: The Food and Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working conditions.
During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
b. During an observation on 10/8/2024 at 8:06 a.m. inside the walk-in refrigerator, 5 of 6 blue racks had chips and rusts.
During an observation on 10/8/2024 at 8:13 a.m. inside the walk-in freezer, 1 of 6 racks had chips.
During an interview on 10/08/2024 at 8:25 a.m. with DS, DS stated the racks had chips and it was not okay because particles could go to the food and contaminate it.
During an interview on 10/8/2024 at 8:31 a.m. with DS, DS stated she was aware of the chips on the shelves in the refrigerator.
During a review of facility's P&P titled Sanitation, dated 4/2024, the Sanitation P&P indicated, (6) Employees are to alert the FNS Director immediately to any equipment needing repair. (7) The FNS Director (and or cook in their absence) will report any equipment needing repair to the maintenance man. (11) All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seam, cracks, and chipped areas.
During a review of facility's P&P titled Refrigerator and Freezer, dated 4/2024, the Refrigerator and Freezer P&P indicated (9) Periodically inspect shelves and replace if coating is chipped away exposing metal shelves.
During a review of Food Code 2022, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts.
c. During an observation on 10/8/2024 at 8:13 a.m. in the walk-in freezer, the plastic curtains and door had ice buildup.
During a concurrent observation and interview on 10/08/2024 at 8:35 a.m. with the DS, the DS stated the freezer had ice buildup that could be from hot air going in. DS stated if there was hot air, the food products would not be in proper temperatures and food could spoil and harm the residents.
During a review of the facility's P&P titled Refrigerator and Freezer, dated 4/2024, the Refrigerator and Freezer P&P indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. The best cleaning results, always refer to your owner's manual.
d. During an observation on 10/8/2024 at 10:30 a.m. in the preparation area, [NAME] 1 was wearing gold bracelet while molding the dough of the biscuit.
During an interview on 10/9/2024 at 10:45 a.m. with the DS, the DS stated she asked [NAME] 1 to remove the jewelry yesterday as the staff were not allowed to wear jewelries in the kitchen for infection control purposes.
During a review of the facility's P&P titled Dress Code, dated 4/2024, the Dress Code P&P indicated Proper Dress: (7) No excessive jewelry, just wedding rings on hand, non-dangling earrings on ears, and wristwatch. Wristwatch and wedding rings needed to be covered with gloves when handling food.
A review of Food Code 2022, the Food Code 2022 indicated 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.
e.
During an observation on 10/8/2024 at 10:50 a.m. the mixer had dried food buildup.
During a concurrent observation interview on 10/9/2024 at 1:11 p.m. with [NAME] 1 and the DS, the internal parts of the mixer had dried up food. [NAME] 1 stated she did not use the mixer today and it was cleaned yesterday. DS stated the inside part of the mixer had dried food debris and it needed to be cleaned to prevent contamination issues.
During a review of facility's P&P titled Electrical Food Machines, dated 4//2024, the Electrical Food Machines P&P indicated, Keep and maintain all food machines in good operating, sanitary condition. This includes mixers, grinders, slicers, and toasters. (3) Clean the beater shaft and body of the machine with warm water and detergent following manufacturer's instructions. Hard scrubbing and harsh soaps might remove the paint. (4) After washing and rinsing, allow beater and bowl to air dry. Then store in the proper place.
During a review of Food Code 2022, the Food Code 2022 indicated, 4-602.12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph 4-602.11 (D)(6).
f. During an observation on 10/8/2024 at 11:01 a.m. in the preparation area, the roof of the rack had dirt buildup.
During an interview on 10/08/2024 at 11:03 a.m. with Assistant Dietary Supervisor (ADS), the ADS stated the preparation areas were cleaned every shift. The ADS stated the roof of the rack had dirt buildup and it should be cleaned to prevent cross-contamination. The ADS stated cross-contamination could harm the residents and could get sick of foodborne illnesses.
During a review of facility's P&P titled Sanitation, dated 4/2024, the Sanitation P&P indicated, (16) The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures, and the good over stove, which will be cleaned by the maintenance staff.
During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
g. During concurrent observation and interview on 10/8/2024 at 11:02 a.m. the red, green chopping board had scratches and the blue chopping board was sticky to touch in the clean area.
During an interview on 10/8/2024 at 11:05 a.m. with the ADS, the ADS stated the blue chopping board was dirty and it was in the clean area that could cause cross-contamination. The ADS stated the red and green chopping boards are used up as it had lines. The ADS stated residue could go to the food as physical contaminants. The DS stated chopping boards that had scratches could attract bacteria.
During a review of facility's P&P titled Sanitation, dated 4/2024, the Sanitation P&P indicated (12) Plastic ware, china, and glassware that becomes unsightly, sanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining. (20) Separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized.
During a review of Food Code 2022, the Food Code 2022 indicated, 3-302.11 Packaged and Unpackaged Food-Separation, Packaging, and Segregation. (2) Except when combined as ingredients, separating types of raw animals from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: (b) Arranging each type of food in equipment so that cross-contamination of one type with another is prevented and (c) Preparing each type of food at different times or in separate areas.
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 have a policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanit...
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Based on observation, interview, and record review the facility failed to have a policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption when the policy did not include shelf life for prepared foods for storing food brought in by family and other visitors and there was no designated refrigerator for resident's outside food sources.
This deficient practice had the potential to cause a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 138 of 139 facility residents.
Findings:
A review of the facility's Policies and Procedures (P&P) titled Food for Residents from Outside Source dated 4/2024, indicated Policy Statement: Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Policy interpretation and Implementation:
Food bought by family/visitors is left with resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food.
o
Non-perishable foods will be stored in re-sealable containers with tight-fitting lids. Intact fresh fruit maybe stored without a lid.
o
Perishable food must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with resident's name, the item and the use by date.
The nursing staff will discard perishable foods on or before the use by date.
The P&P did not indicate any guidelines on shelf life of prepared and perishable foods.
During an interview on 10/9/2024 at 2:55 p.m. with Dietary Supervisor (DS), DS stated they have a designated refrigerator located in the nurses' station to store food from the outside source but needed to confirm.
During a record review on 10/9/2024 at 2:23 p.m. of a text message of the DS, the DS text message indicated they do not have a shared refrigerator for storing food from home for the residents in the nurse's station.
During an interview on 10/10/2024 at 11:40 p.m. with Registered Nurse 1 (RN 1) he was not familiar with the food from home policy.
During an interview on 10/10/2024 at 11:49 a.m. with the Director of Nursing (DON), the DON stated resident's friends and relatives could bring food from the outside if the resident's finished it in one meal. DON stated they do not have a refrigerator for storing food from outside source for the resident. DON stated the food would go to waste and it would be spoiled if residents kept the food at the bedside because it would not be on proper temperatures. The DON stated the food would not be safe for consumption and residents could have food borne illnesses as a potential harm. The DON stated residents could also be disappointed for not having a safe storage space for their food if they wanted to eat it later.
During an interview on 10/10/2024 at 11:56 a.m. with the Director of Staff Development (DSD), the DSD stated he did not do any in-services yet regarding resident's food from outside sources but planned to re-in servicing the staff about it.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not maintaining the trash area free from trash, plastic, plastic cups, plastic contain...
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Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not maintaining the trash area free from trash, plastic, plastic cups, plastic containers, soiled gloves, paper bag of food, papers on the dumpster's (a large trash metal container designed to be emptied into a truck) floor.
This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 138 of 139 facility residents.
Findings:
During an interview on 10/9/2024 at 1:41 p.m with the Dietary Supervisor (DS), the DS stated the trashes from the kitchen were taken out to the dumpster after every meal.
During an observation on 10/9/2024 at 2:45 p.m. in the dumpster area, while two kitchen staff were throwing the kitchen trash, it was observed that there were trashes such as paper bag of food, soiled gloves, plastic cups, plastic containers, papers were on the floor.
During a concurrent observation and interview on 10/9/2024 at 2:49 p.m. with the Environmental Service Director (EVSD), EVSD stated they used the power wash the dumpster area once a month for cleaning. The EVSD stated the area was not clean and free from trash and the plan was to get new trash bins and clean the area today. The EVSD stated it was important to maintain the cleanliness of the dumpster area for infection control as fly could be attracted and could spread diseases to residents.
During a review of facility's Policies and Procedures (P&P) titled Miscellaneous Areas, reviewed 4//2024, Miscellaneous Areas P&P indicated, Trash Procedure: (2) Garbage and trashcan must be inspected daily that no debris is on the ground or surrounding areas, and that the lids are closed. Trash Collection Area: The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. (1) The area must be swept and washed down by maintenance with a detergent on a regular basis. If a commercial service is used, arrangements must be made for periodic exchange of trash bins.
During a review of Food Code 2022, indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 385's admission Record (AR), the AR indicated the facility admitted the resident on 10/3/2024, wi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 385's admission Record (AR), the AR indicated the facility admitted the resident on 10/3/2024, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and dependence on supplemental oxygen (a medical treatment that provides extra oxygen to people who have breathing problems or low blood oxygen levels).
During a review of Resident 385's MDS dated [DATE], the MDS indicated the resident had intact cognition (the ability to maintain a relatively high level of mental functioning, including thinking, learning, memory, and perception).
During a review of Resident 385's History and Physical (H&P), dated 10/11/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 385's Order Summary Report, the report indicated and order for:
10/5/2024 Albuterol sulfate nebulization solution (2.5 milligrams [mg, a unit of weight]/3 milliliters [ml, a unit of volume]) 0.083%. 3 milliliters inhale orally via nebulizer every six hours for shortness of breath.
10/3/2024 Budesonide inhalation suspension 0.5 mg/2 ml (Budesonide [Inhalation]). 2 ml inhale orally two times a day for COPD.
During an observation and interview on 10/8/2024 at 9:37 a.m., with LVN 4, inside Resident 385's room, observed Resident 385's nebulizer machine at the bedside with the mask and the tubing touching the floor with no date on the tubing of when it was last changed. LVN 4 stated the tubing should be labeled with the date it was last changed to prevent the staff from using old tubing that can harbor bacteria and viruses that can make the resident sick, and when the nebulizer tubing and mask is not in use it should be stored in a plastic bag to prevent the tubing from dangling on the floor to prevent infection. LVN 1 was observed disposing off the nebulizer tubing and replaced the machine with a new nebulizer mask and tubing and labeled the tubing with the date it was changed.
During an interview on 10/11/2024, at 2:09 p.m., with the Director of Nursing (DON), the DON stated LVN 4 did the right thing by removing the contaminated nebulizer tubing and mask touching the floor that was not dated with the date it was last changed and replaced them with a new nebulizer tubing with a mask and labeled the date it was changed due to the risk for infection that can make the resident sick with a respiratory illness.
During a review of the facility's recent P&P titled Infection Prevention and Control Program, last reviewed on 4/2024, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
3.a. During a review of Resident 131's admission Record (AR), the AR indicated the facility admitted the resident on 9/16/2024, and readmitted the resident on 9/25/2024, with diagnoses including pressure ulcer of left buttock stage 3 (the skin develops an open, sunken hole called a crater or ulcer) and intellectual disabilities (a lifelong condition that limits a person's mental functioning and skills, such as communicating, taking care of themselves, and social skills).
During a review of Resident 131's H&P, dated 9/27/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 131's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and sometimes understand others.
During a concurrent observation and interview on 10/8/2024, at 10:31 a.m., during resident screening, inside Resident 131's room, with Certified Nursing Assistant 9 (CNA 9), observed Resident 131's urinal bottle at the resident's bedside drawer without the resident's name or room number. CNA 9 stated the urinal bottle should be labeled with the name or room number of the resident to prevent switching of urinals from other residents that can cause contamination getting the resident sick.
During an interview on 10/11/2024, at 2:10 p.m., with the DON, the DON stated the urinal bottle should be labeled with the name of the resident or resident's initials or room number to prevent switching urinal bottle with other residents that can cause infection.
During a review of the facility's recent P&P titled Infection Prevention and Control program, last reviewed on 4/2024, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
3.b. During a review of Resident 70's admission Record (AR), the AR indicated the facility admitted the resident on 5/3/2024, with diagnoses including surgical amputation (the surgical removal of a body part, such as a finger, toe, hand, foot, arm, or leg) and gastritis (a condition where the stomach lining becomes inflamed, or swollen and red).
During a review of Resident 70's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others.
During a concurrent observation and interview on 10/8/2024, at 10:21 a.m., with Certified Nursing Assistant 11 (CNA 11), observed two urinal bottles without label hanging at the foot part of the resident's bed. CNA 11 stated the urinal bottles should be labeled with the resident's name to prevent switching of urinals with other residents to prevent spread of infection.
During an interview on 10/11/2024, at 2:10 p.m., with the DON, the DON stated the urinal bottle should be labeled with the name of the resident or resident's initials or room number to prevent switching urinal bottle with other residents that can cause infection.
During a review of the facility's recent P&P titled Infection Prevention and Control Program, last reviewed on 4/2024, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
4. During a review of Resident 65's admission Record (AR), the AR indicated the facility admitted the resident on 5/28/2024, and readmitted the resident on 8/15/2024, with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), and coronavirus disease (COVID-19, a virus identified as the cause of an outbreak of respiratory illness).
During a review of Resident 65's H&P, dated 6/4/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 65's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy (a treatment that provides extra oxygen to help people breathe and function when their body does not get enough oxygen from the air).
During a review of Resident 65's Order Summary Report, dated 5/28/2024, the report indicated an order for oxygen at 2 liters per minute (L/min, a unit of measurement that describes the flow rate of a substance in liters per minute) via nasal cannula to keep O2 sats above 92%. Dx: COPD with exacerbation. PRN.
During a concurrent observation and interview on 10/8/2024, at 10:45 a.m., with LVN 4, inside Resident 65's room, observed Resident 65's oxygen via nasal cannula 9a medical device that provides supplemental oxygen to patients through two prongs inserted into the nostrils) tubing without a label of the date it was last changed. LVN 4 stated the oxygen tubing via nasal cannula should be dated so the staff will know when to change them again to prevent infection.
During an interview on 10/11/2024, at 2:09 p.m., with the DON, the DON stated the staff should have labeled the oxygen tubing with the date it was last changed to know when the tubing is due to be changed to prevent infection.
During a review of the facility's recent P&P titled Infection Prevention and Control Program, last reviewed on 4/2024, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
5. During a review of Resident 390's admission Record (AR), the AR indicated the facility admitted the resident on 11/27/2023, with diagnoses including adult failure to thrive (a syndrome of decline in an elderly person's physical and psychological health), gastrostomy (a surgical procedure used to insert a tube, often referred to as a g-tube, through the abdomen and into the stomach), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 390's H&P, dated 11/29/2023, the H&P indicated the resident cannot make own decisions but can make needs known.
During a review of Resident 390's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and rarely to never had the ability to understand others. The MDS indicated the resident had a feeding tube.
During a review of Resident 390's Order Summary Report, dated 8/28/2024, the report indicated an order of may crush all crushable medications and shake well all liquids/suspension medications.
During an observation and interview on 10/9/2024, at 9:14 a.m., with LVN 1, during medication administration observation, observed LVN 1 placed piston syringe plunger on top of the drawer not wiped with antiseptic wipe in preparation for g-tube administration of medications. LVN 1 stated she should have not placed the plunger on the top of the drawer which was not sanitized to prevent infection to residents.
During an interview on 10/11/204, at 3:19 p.m., with the DON, the DON stated the staff should have not place the plunger on the contaminated surface of the drawer to prevent infection to residents.
During a review of the facility's recent P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, last reviewed on 4/2024, the P&P indicated resident-care equipment including reusable items and durable medical equipment will be cleaned and disinfected according to CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.
During a review of the facility's recent P&P titled Administering Medications through an Enteral Tube, last reviewed on 4/2024, the P&P indicated the purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Administer each medication separately and flush between medications. Use a clean enteral syringe with an ENFit connector to administer medications through an enteral tube.
During a review of the facility's most recent P&P titled Infection Prevention and Control Program, last reviewed on 4/2024, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
6. During an observation on 10/8/2024, at 9:10 a.m., the Hoyer lift sling made of cloth was hanging on the Hoyer lift machine near Station A.
During a concurrent observation and interview on 10/9/2024, at 8:05 a.m., with Certified Nursing Assistant 5 (CNA 5), at the hallway near Station A. The Hoyer lift sling was still hanging on the Hoyer lift machine near Station A. CNA 5 stated the Hoyer lift sling was used for multiple residents in the station. CNA 5 stated the sling was supposed to be for single resident use only and should not be left hanging on the Hoyer lift machine as a staff may use them on another resident that can potentially spread infection. CNA 5 stated the sling should be brought to the laundry room for reprocessing.
During an interview on 10/11/2024, at 2:09 p.m., with the Director of Nursing (DON), the DON stated the Hoyer lift sling (cloth) should not be used on multiple residents as they are intended for single resident use only. The DON stated the cloth slings should be kept inside the resident's room where the cloth sling was assigned to prevent the spread of infection.
During a review of the facility's recent P&P titled Lifting Machine, Using a Mechanical, last reviewed on 4/2024, the P&P indicated to make sure the battery is charged. Sling care:
1. Disinfect slings in between residents (unless disposable).
2. Wash and sanitize according to manufacturer's instructions.
3. Discard any worn, frayed, or ripped slings.
During a review of the facility's recent P&P titled Infection Prevention and Control Program, last reviewed on 4/2024, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
During a review of the facility's most recent P&P titled Safe Lifting and Movement of Residents, last reviewed on 4/2024, the P&P indicated mechanical lifts shall be made readily available to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being charged. Enough slings, in sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single residents use disposable slings.
Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to:
1. Ensure an unlabeled, used urinal bottle was not readily available for resident use for one of three sampled residents (Resident 95) reviewed under the Urinary Catheter (a hollow tube inserted into the bladder to drain or collect urine) or Urinary Tract Infection (UTI- an infection in the bladder/urinary tract) care area and for two residents (Resident 77, and 127) randomly observed during the screening process.
These deficient practices had the potential to spread infections and illnesses among residents and staff.
2. Resident 385's nebulizer tubing (a tube that connects the air compressor to the medication cup in a nebulizer) with the mask was not touching the floor and was dated with the date it was last changed for one of three sampled residents investigated under respiratory care.
3. Resident 131 and 70's urinal bottles were labeled with the name or room number for two of three sampled residents investigated under urinary tract infection (UTI).
4. Resident 65's oxygen tubing via nasal cannula (a medical device that provides supplemental oxygen to patients through two prongs inserted into the nostrils) was labeled with the date it was last changed for one of three sampled residents investigated under respiratory care.
5. Licensed Vocational Nurse 1 (LVN 1) failed to ensure the irrigation syringe plunger (the part that moves up and down to create a vacuum that pulls liquid into the syringe) was not placed on top of the contaminated drawer while manipulating the gastrostomy tube (g-tube, a small, flexible tube that is surgically inserted through the abdomen and into the stomach to provide nutrition, fluids, and medicine) of Resident 90 for the medication to be infused during medication administration facility task.
6. The Hoyer lift sling (cloth) (a device that is used to transfer patients from one surface to another using a Hoyer lift) was for single resident use only.
These deficient practices had a potential to spread infections and illnesses among residents.
7. Ensure Resident 104's oxygen tubing (a flexible, clear hose that delivers oxygen to a patient during oxygen therapy that is connected to an oxygen source) was not touching the floor.
8. Ensure Resident 116's oxygen tubing was changed according to the facility's policy and procedures (P&P).
These deficient practices had a potential to spread infections and illnesses among residents.
9. Ensure washer water temperature, dryer temperatures, and lint trap cleaning were recorded.
This deficient practice had the potential to result in ineffective disinfection and accumulation of lint that may ignite and cause a fire.
10. Ensure linen cart covers were made of nonporous (does not allow liquid or air to pass through it) materials and ensure Laundry Staff 1 (LS 1) was knowledgeable of disinfectant contact time (the amount of time required for a surface to remain wet for your disinfectant to be fully effective) when cleaning linen carts.
These deficient practices had the potential to expose clean linens to dust, smoke, and or airborne contaminants.
11. Develop water management program (identify hazardous conditions and take steps to minimize the growth and transmission of Legionella [a bacteria that can cause Legionnaire's disease (a serious type of pneumonia [an infection that inflames the air sacs in one or both lungs]) and Pontiac fever (a mild flu-like illness caused by exposure to Legionella bacteria)] and other waterborne pathogens in building water system) for that is based on Centers for Disease Control and Prevention (a national public health agency in the United States) and American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE - a nonprofit organization that develops and publishes standards for the heating, ventilating and air conditioning industry) recommendations for developing a Legionella water management program for two of two months (September 2024 and October 2024) reviewed under Infection Control facility task.
This deficient practice had the potential to spread infectious microorganisms and placed all the
residents and staff at risk for Legionella exposure and other water borne pathogens resulting in
serious illnesses including severe pneumonia requiring hospitalization.
Findings:
1.a. During a review of Resident 95's admission Record, the admission Record indicated the facility admitted the resident on 5/31/2024 and readmitted the resident on 4/3/2024 with diagnoses that included paraplegia (loss of movement and/or sensation, to some degree, of the legs), overactive bladder, and neuromuscular (relating to nerves and muscles) dysfunction of the bladder.
During a review of Resident 95's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/6/2024, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required supervision with personal hygiene, dressing, and toileting.
1.b. During a review of Resident 127's admission Record, the admission Record indicated the facility admitted the resident on 8/15/2024 and readmitted the resident on 9/11/2024 with diagnoses that included displaced fracture (broken bone) of medial malleolus (small prominent bone on the inner side of the ankle) of left tibia (shin bone), fracture of upper and lower end of left fibula (outer end of the two bones between the knee and the ankle), and muscle weakness.
During a review of Resident 127's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required supervision with eating, oral hygiene, personal hygiene, dressing, and toileting.
1.c. During a review of Resident 77's admission Record, the admission Record indicated the facility admitted the resident on 7/19/2024 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting right dominant side, and muscle weakness.
During a review of Resident 77's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required partial/moderate assistance with personal hygiene, dressing, bathing, and toileting.
During an observation and interview on 10/8/2024 at 9:15 a.m., in Resident 77, 95, and 127s shared room; observed Resident 77 sitting in his wheelchair (WC), Resident 95 sitting in his motorized WC, and Resident 127 sitting on his bed. Observed a used, unlabeled urinal hanging from the metal hand rail in the restroom.
During a concurrent interview and observation on 10/8/2024 at 9:30 a.m., with Certified Nursing Assist 3 (CNA 3), observed CNA 3 entered the shared restroom and stated the urinal was not labeled and she does not know which resident the urinal belonged to. CNA 3 stated if the urinal is left in the restroom, it should be labeled. CNA 3 stated she would throw out the urinal because she was not sure which resident if belonged to.
During an interview on 10/11/2024 at 8:58 a.m., with the Director of Nursing (DON), the DON stated all urinals should be labeled immediately when staff provide them and bring them into a resident's room. The DON stated the importance of labeling the urinals was to prevent residents from using urinals that did not belong to them. The DON stated it was an infection control issue and urinals were a personal belonging that could potentially cause cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). The DON stated the facility policy and procedure was not followed when the urinal was not labeled.
During a review of the facility P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment,' last reviewed 4/2025, indicated resident-care equipment, including reusable items, will be cleaned and disinfected. Single resident reusable - use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g. urinals).
During a review of the facility P&P titled, Infection Prevention and Control, last reviewed 4/2025, indicated an infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures.
7. During a review of Resident 104's admission Record, the admission Record indicated the facility admitted the resident on 10/1/2023 with diagnoses including type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high), history of falling, and dependence on supplemental oxygen.
During a review of Resident 104's H&P dated 10/4/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 104's MDS dated [DATE], the MDS indicated the resident had an intact cognition and required set-up or clean-up assistance with eating; supervision/touching assistance with rolling left and right; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 104's Order Summary Report, the Order Summary Report indicated the following physician's orders:
10/1/2023: Oxygen at three (3) liters per minute (L/min - a unit of measurement) via nasal cannula (NC - a thin, flexible tube with 2 prongs that delivers oxygen to a patient thru the nose) to keep oxygen saturation (a measurement of how much oxygen is in the blood compared to how much it could carry) above 92 percent (% - a unit of measurement) continuous every shift.
During a review of Resident 104's care plan on altered respiratory status initiated on 6/4/2024 and last revised on 7/11/2024, the care plan indicated to administer oxygen at 3 L/min via NC to maintain oxygen saturation at above 92% every shift.
During an observation on 10/8/2024 at 11:58 a.m., inside Resident 104's room with LVN 5, LVN 5 stated the resident's oxygen tubing was not placed inside the plastic storage bag and was touching the floor. LVN 5 stated the oxygen tubing should not have been touching the floor as the floor was dirty and already contaminated the tubing which may lead to resident getting an infection. LVN 5 stated oxygen tubing were supposed to be placed inside the plastic storage when not in use.
During an interview on 10/11/2024 at 3:30 p.m., the DON stated oxygen tubing were supposed to be placed inside the plastic storage bag when not in use. The DON stated Resident 104's oxygen should have been inside the plastic storage bags and not touching the floor. The DON stated the oxygen tubing got contaminated already and the resident can acquire infection from a contaminated tubing.
During a review of the facility's P&P titled, Infection Prevention and Control Program (IPCP), last reviewed 4/12/2024, the P&P indicated an IPCP is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The P&P indicated important facets of infection prevention include but not limited to instituting measures to avoid complications or dissemination, and educating staff and ensuring that they adhere to proper techniques and procedures.
8. During a review of Resident 116's admission Record, the admission Record indicated the facility admitted the resident on 5/31/2024 and readmitted the resident on 7/31/2024 with diagnoses including history of falling, malignant neoplasm of breast (abnormal growth of tissue in the breast capable of spreading to other parts of the body), and psychosis (a condition that affects the brain and causes the individual to believe and experience things that are not real).
During a review of Resident 116's H&P dated 8/6/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 116's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition and required set-up or clean-up assistance with eating; supervision/touching assistance with rolling left and right, sit to lying, lying to sitting on edge of bed, sit to stand, and ambulating up to 150 feet; partial/moderate assistance from staff with all other ADLs.
During a review of Resident 116's Order Summary Report, the Order Summary Report indicated the following physician's orders dated 8/2/2024:
o
Oxygen at 2 L/min via NC to keep oxygen saturation above 90 % for comfort measures as needed.
o
Oxygen - change oxygen tubing on Sunday of every week one time a day every Sunday.
During a concurrent observation and interview on 10/8/2024 at 11:49 a.m., inside Resident 104's room with LVN 4, LVN 4 verified the date on Resident 116's oxygen tubing was 9/22/2024. LVN 5 stated oxygen tubing were supposed to be changed every week on Sundays. LVN 4 stated the oxygen tubing had not been changed for more than 2 weeks. LVN 4 stated the tubing should have been changed weekly on Sundays as indicated in the physician's orders. LVN 4 stated it was an infection control issue as the resident can acquire infection from an oxygen tubing that was not changed as scheduled.
During an interview on 10/11/2024 at 10:06 a.m., the Minimum Data Set Nurse 1 (MDSN 1) stated oxygen tubing should be changed every week on Sundays. MDSN 1 stated if the date on the oxygen tubing indicated 9/22/2024, the tubing was more than 2 weeks old. MDSN 1 stated Resident 116's oxygen tubing should have been changed as scheduled on Sundays as it was an infection control issue, and the resident could get an infection from the tubing that was not changed.
During a review of the facility's P&P titled, Infection Prevention and Control Program (IPCP), last reviewed 4/12/2024, the P&P indicated an IPCP is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The P&P indicated important facets of infection prevention include but not limited to instituting measures to avoid complications or dissemination, and educating staff and ensuring that they adhere to proper techniques and procedures.
9. During a concurrent interview and record review on 10/10/2024 at 9:48 a.m., reviewed the washer water temperature log, dryer temperature log, and lint trap cleaning log with LS 1. LS 1 stated there were no initials on the logs for 10/9/2024 afternoon shift. LS 1 stated they were supposed to sign/initial the logs after they have completed the tasks (checking the water temperature, checking the dryer temperature, and cleaning the lint trap).
During an interview on 10/11/2024 at 3:30 p.m., the DON stated the laundry water temperature log, dryer temperature log, and the lint trap log should be checked and completed. The DON stated it is important to ensure the checks were done as part of infection control to ensure proper temperatures to kill bacteria during the laundry process.
During a review of the facility's P&P titled, Surveillance for Infections, last reviewed 4/2024, the P&P indicated the surveillance should include a review of any or all the following information to help identify possible indicators of infections including temperature logs.
During a review of the facility's P&P titled, Quality Control, Environmental Services, last reviewed 4/2024, the P&P indicated quality control records are maintained by the department directors and a copy of each record is provided to the facility Quality Assessment and Assurance Committee (responsible for ensuring quality of care and quality of life in the facility) monthly.
10. During an interview on 10/10/2024 at 10:11 a.m., LS 1 stated she cleans and sprays the linen cart used for clean linens with disinfectant daily. LS 1 stated if the linen cart has rips or tears, she would inform the laundry supervisor.
During a concurrent observation and interview on 10/11/2024 at 8:10 a.m., in the hallway outside of the clean linen room, LS 1 stated she sprays the linen carts with the disinfectant cleaner. LS 1 stated she sprays the disinfectant cleaner on the linen cart and leaves the disinfectant cleaner on the linen cart for 20 seconds and after 20 seconds she wipes the surface of the linen cart down.
LS 1 stated the linen cart cover is made of porous (something is full of tiny holes or openings that allow air, water, or light to pass through) material where air and water can pass through. The Maintenance Supervisor (MS) stated the disinfectant cleaner is used for nonporous materials to disinfect the linen cart (including its cover) and to kill the viruses. The MS stated the disinfectant cleaner container indicated 10 minutes of contact time which [TRUNCATED]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
Deficiency Text Not Available
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Deficiency Text Not Available
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 maintain sanitary conditions in the food services dep...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when seven (7) flies (a type of insect) were observed in the kitchen.
This deficient practice had a potential to result in 138 of 139 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.
Findings:
During an observation on 10/8/2024 at 8:05 a.m. one (1) fly was flying around the preparation area.
During an observation on 10/8/2024 at 11:08 a.m. 1 fly was flying around the kitchen.
During an observation on 10/8/2024 at 11:18 a.m. 1 fly landed on the back screen door. The back door had a little space for fly entry.
During an observation on 10/8/2024 at 11:37 a.m. 1 fly landed on the food preparation area.
During a concurrent observation and interview on 10/8/2024 at 11:58 a.m. with the Dietary Supervisor (DS), there was 1 fly flying around the tryline area. The fly landed on one of the employees' body parts. DS stated there was a fly in the kitchen.
During an observation on 10/8/2024 at 12:05 p.m. in the trayline (area where food was assembled), there was a fly flying around.
During an observation on 10/8/2024 at 12:28 p.m. 1 fly landed on the scoop used for soft mechanical diet (diet consistent of foods that are chopped and soft in texture) in trayline.
During an interview on 10/9/2024 at 10:34 a.m. with the Registered Dietitian (RD), the RD stated they have a pest control program, and their last visit was September 2024. The RD stated it was important to have a kitchen that was pest-free to make sure the foods were not contaminated. The RD stated pest would carry diseases in food preparation and would contaminate food. The RD stated residents could get sick with nausea and vomiting as a potential outcome of eating contaminated food.
During an interview on 10/9/2024 at 10:40 a.m. with the DS, the DS stated the pest control vendor was in the facility last Friday. The DS stated it was not okay to have flies in the kitchen as it was not sanitary because it could contaminate foods. The DS stated food borne illnesses would be the potential outcome to the residents.
During a review of facility's Policies and Procedures (P&P) titled Miscellaneous Areas, reviewed 4/2024, Miscellaneous Areas P&P indicated, Fly and Vermin Control. Flies are carriers of disease and are a constant enemy of high standards of sanitation in the Food and Nutrition Services Department. Suggestions for fly and vermin control:
1.
All doors and windows must be properly screened.
2.
Food must be properly covered and stored.
3.
The Food and Nutrition Services Department [NAME] be kept free soil and clutter.
4.
Arrangements should be made by the administrator for pest control service on a routine basis.
During a review of the facility's P&P titled Pest Control, reviewed 4/2024, the Pest Control P&P indicated, Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: (1) This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. (3) Window are screened at all times.
During a review of Food Code 2022, the Food Code 2022 indicated 6.501.111 Controlling Pests. The premises shall be maintained free of insects, rodents and other pests shall be controlled to eliminate their presence on the premises by:
(A)
Routinely inspecting incoming shipments of food and supplies.
(B)
Routinely inspecting the premises for evidence of pests.
(C)
Using methods, if pests are found, such as trapping devices or other means of pest control specified under §§ 7-202.12, 7-206.12, and 7-206.13.
(D)
Eliminating harborage conditions.
Sept 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for two...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for two of four sampled residents (Resident 3 and Resident 4) when on 9/1/2024 at 9:30 a.m.:
1. Resident 3 stated Resident 4 punched Resident 3 on the left side of his cheek.
2. Resident 3 stated he hit Resident 4 on his right cheek.
3. Resident 4 stated he punched Resident 3.
This deficient practice resulted in Resident 3 and Resident being subjected to abuse while under the care of the facility.
Findings:
a. A review of Resident 3 admission Record indicated the facility admitted the resident on 9/19/2016 and was readmitted on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions] symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression) depressive type, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things and activities you once enjoyed), and suicidal ideations (when you think about killing yourself).
A review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/13/2024, indicated Resident 3 had the ability to be understood and had the ability to understand. The MDS indicated Resident 3 required partial assistance (helper does less than half the effort) with showering and requires supervision or touch assistant (helper provides verbal cues and or touching, steadying, and or contact guard assistance) with oral hygiene, toileting, upper and lower body dressing, putting on and taking off footwear, and with personal hygiene.
A review of Resident 3's Change in Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains documentation) Evaluation, dated 9/1/2024 at 9:46 a.m., indicated Licensed Vocational Nurse 2 (LVN 2) heard from the residents' room Resident 4 saying, come on, come on, and upon checking LVN 2 found Resident 3 standing in the middle of the room with the roommate (Resident 4) standing and inviting Resident 3 to fight. Resident 3 claimed that he was punched by his roommate (Resident 4) on the left cheek.
A review of Resident 3's Care plan, developed on 9/1/2024, for the resident's risk for emotional distress related to physical altercation with another resident. The interventions included to conduct a body assessment to identify any injury, encourage verbalization of feelings and concerns and address appropriately.
A review of Social Services Noted, dated 9/2/2024 at 11:05 a.m., indicated Social Services Director (SSD) met with Resident 3 and Resident 3 stated he was watching TV and Resident 4 was yelling at him, so he (Resident 3) got up to tell him (Resident 4) to stop yelling at him (Resident 3). Resident 4 got up and put his fists up and then punched him (Resident 3). Resident 3) punched him (Resident 4) back and pushed him (Resident 4) away. When Resident 3 asked if he was in any pain or discomfort Resident 2 stated No, I'm fine. My cheek is little sore, but I am ok.
During an interview on 9/9/2024 at 10 a.m., Resident 3 stated his roommate (Resident 4) was picking on him so Resident 3 confronted him. Resident 3 stated Resident 4 would get upset that Resident 3 had his TV on too loud. Resident 3 stated that on the day of the incident (cannot recall date) Resident 4 came to him and started complaining to him and Resident 3 got up and stood up to Resident 4, that was when Resident 4 punched Resident 3 on the left side of his cheek. Resident 3 stated he swung back and hit Resident 4 on his right cheek and that is when the nurse (LVN 2) came in. Resident 4 stated he no injuries but his right cheek was sore.
b. A review of Resident 4 admission Record indicated the facility admitted the resident on 12/04/2018 and readmitted the resident on 8/21/2024 with diagnoses that included insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep), essential (primary) hypertension (when the pressure in your blood vessels is too high [140/90 mmHg or higher]), and peripheral vascular disease (a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm, or become blocked).
A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had the ability to be understood and had the ability to understand. The MDS indicated Resident 4 had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) that occurred four to six days. The MDS indicated Resident 4 was independent (activity is done by themselves with no assistance) with oral hygiene, toileting, showering, upper and lower body dressing, putting on and off footwear, and personal hygiene.
A review of Resident 4's Care plan, developed on 7/16/2023, for resident's potential to be verbally aggressive related to mental and emotional illness, screaming, yelling and crying spell, aggressive behavior towards staff. The interventions included to monitor behaviors, provide positive feedback for good behavior, and when Resident 4 becomes agitated, staff needs to intervene before agitation escalates.
A review of Resident 4's Care plan, developed on 12/27/2023, for resident's disruptive behavior such as screaming and yelling, pacing back and forth from the hallway to the room and with interventions that included Resident 4 for psychology consult, and to approach resident in a calm manner.
A review of Resident 4's COC, dated 9/1/2024 at 9:47 a.m., indicated LVN 2 heard from the residents' room Resident 4 saying, come on, come on, and upon checking LVN 2 found Resident 3 standing in the middle of the room with the roommate (Resident 4) standing and inviting Resident 3 to fight. Resident 4 claimed that he punched his roommate (Resident 3), but Resident 4 changed his story later and denied hitting the roommate (Resident 3).
A review of Resident 4's Care plan, developed on 9/1/2024, indicated with observed episode of behavior physical aggression with another resident. The interventions included keep residents separated as much as possible, monitor resident for any physical aggression, and to encourage resident to express feelings verbally instead of physical.
During an interview on 9/9/2024 at 1:34 p.m., LVN 2 stated that on Sunday 9/1/2024 at 9:30 a.m., she was in station 4 preparing the medications when LVN2 heard an unusual sound a firm voice (Resident 4) saying, come on, come on. LVN 2 stated she ran into the residents' room and saw Resident 3 and Resident 4 standing in a fight position, like they were ready to fight. LVN 2 stated Resident 4 stated he punched Resident 3 then denied punching Resident 3. LVN 2 stated Resident 3 stated Resident 4 hit him and Resident 3 pointed to his left side of his face. LVN 2 stated Resident 4 then finally said he had hit Resident 3.
During an interview on 9/9/2024 at 2:07 p.m., Registered Nurse 2 (RN 2) stated on Sunday 9/1/2024 at 9:45 a.m. was told by LVN 2 that Resident 3 stated he was hit by Resident 4. RN 2 stated went to assess Resident 3 and Resident 3 stated he was hit on his left side.
During an interview on 9/10/2024 at 11:13 a.m., the Director of Nursing (DON) stated the incident occurred around 9:30 a.m. to 10 a.m. and was told Resident 3 and Resident 4 had an altercation. The DON stated LVN 2 stated she heard come on, when LVN2 came into the residents' room and observed Resident 3 and Resident 4 in boxing position. The DON stated it is the facility's policy that all residents are free from abuse. The DON stated Resident 4 was sent out for the alleged abuse because we treated it as abuse.
During an interview on 9/10/2024 at 12:15 p.m., the Administrator (Adm) stated educated Resident 4 many times and care planned behaviors, not sure what happened here because Resident 3 alleged Resident 4 hit him in the cheek or eye. The Adm stated all residents must be free from abuse.
A review of the facility's policy titled, Resident Rights, revised on 12/2021, indicated federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident's right to:
c. Be free from abuse, neglect, misappropriation of property, and exploitation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to readmit one of four sampled residents (Resident 4).
This deficient resulted in Resident 4's rights to be violated.
Findings:
A review of Re...
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Based on interview and record review, the facility failed to readmit one of four sampled residents (Resident 4).
This deficient resulted in Resident 4's rights to be violated.
Findings:
A review of Resident 4 admission Record indicated the facility admitted the resident on 12/04/2018 and readmitted the resident on 8/21/2024 with diagnoses that included insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep), essential (primary) hypertension (when the pressure in your blood vessels is too high [140/90 mmHg or higher]), and peripheral vascular disease (a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm, or become blocked).
A review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/6/2024, indicated Resident 4 had the ability to be understood and had the ability to understand. The MDS indicated Resident 4 had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) that occurred 4 to 6 days. The MDS indicated Resident was independent (activity is done by themselves with no assistance) with oral hygiene, toileting, showering, upper and lower body dressing, putting on and off footwear, and personal hygiene.
A review of Resident 4's Care plan, developed on 7/16/2023, indicated the resident had the potential to be verbally aggressive related to mental and emotional illness, screaming, yelling, and crying spell, aggressive behavior towards staff. The interventions included to monitor behaviors, provide positive feedback for good behavior, and when resident becomes agitated staff should intervene before agitation escalates.
A review of Resident 4's Care plan, developed on 12/27/2023, indicated the resident's disruptive behavior such as screaming and yelling, pacing back and forth hallway to room with interventions that included psychology consult, and to approach resident in a calm manner.
A review of the COC, dated 9/1/2024 at 9:47 a.m., indicated LVN 2 heard from the residents' room Resident 4 saying, come on, come on, and upon checking LVN 2 found Resident 3 standing in the middle of the room with the roommate (Resident 4) standing and inviting Resident 3 to fight. Resident 4 claimed that he punched his roommate (Resident 3), but Resident 4 changed his story later and denied hitting the roommate (Resident 3).
A review of Resident 4's Care plan, developed on 9/1/2024, indicated the resident with observed episode of behavior physical aggression with another resident. The interventions included to keep residents separated as much as possible, monitor resident for any physical aggression, and to encourage resident to express feelings verbally instead of physical.
A review of Resident 4's Progress Noted, date 9/1/2024 at 12:45p.m,. indicated the ambulance came to pick up Resident 4 for hospital transfer for behavioral evaluation however Resident 4 strongly refused to go.
A review of Resident 4's Progress Note dated, 9/2/2024 at 8:45a.m., the transportation arrived and approached Resident 4 in his room to inform him of his transfer. Resident 4 started getting agitated and aggressive behavior walking back and forth, waggling his arms saying, am not going.
A review of Resident 4's Progress Note, dated 9/2/2024 at 8:55 a.m., the Director of Nursing (DON) stated 911 (the telepohone number to call for emergency services) was called to transfer Resident 4 urgently to the hospital on a 5150 (is the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled). At 9:10 a.m., seven Emergency medical technicians (EMTs- provide life-saving care to patients at the scene of an emergency and during transportation in an ambulance en route to a hospital) showed up and sent Resident 4 to the hospital.
A review of Resident 4's General Acute Care Hospital 1 (GACH 1) records titled, Discharge Reconciliation, dated 9/7/2024 at 11:59 a.m., indicated Resident 4 was discharged to a skilled nursing facility.
A review of Resident 4's Progress Note, dated 9/7/2024 at 3p.m., the DON indicated she spoke to Medical Doctor (MD 1) who stated nothing can do to help to place Resident 4 to a behavioral unit since Resident 4 is not having suicidal ideation. MD 1 stated that as of right now Resident 4 is not showing any symptoms.
During an interview on 9/9/2024 at 3:36 p.m., the Admissions Coordinator (AC) stated GACH 1 did sent referral for readmission. The AC stated got the referral on Sunday (9/8/2024) which included the discharge planning, but not sure when Resident 4 was discharged .
During an interview on 9/10/2024 at 10a.m., Case Manager 1 (CM 1) from GACH 1 stated Resident 4 was discharged on 9/9/24 and went to Skilled Nursing Facility 2 (SNF 2). In a concurrent interview with Case Manager 2 (CM 2), CM2 stated SNF 1 was not willing to accept Resident 4 back. CM 2 stated SNF 1 would not accept Resident 4 back to the facility due to his behaviors.
During a concurrent record review and interview on 9/10/2024 at 11:13 a.m., the DON stated Resident 4 was sent out on 9/2/2024. The DON stated the last time DON spoke to GACH 1 it was suggested Resident 4 be placed in a private room due to behavioral issues. The DON stated it is the SNF 1's responsibility to readmit Resident 4 because he is our resident.
During an interview on 9/10/2024 at 12:15 p.m., the Administrator (Adm) stated he did get a referral for readmitting Resident 4 and the goal was to get into a location suited for behaviroal to ensure abuse free environment wanted to ensure Resident 4's safety and other residents. The Adm stated the facility's policy for readmitting is to observe the 7-day bed hold wherein any resident can come back into facility unless resident refuses. The Adm stated Resident 4 was still within the bed hold period. The Adm stated there is a risk for not readmitting our residents back to facility. The Adm stated the residents have a right to their bed hold and return to their facility.
A review of the facility's policy titled, readmission to the Facility, revised on 3/2017, indicated residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. readmission procedures apply equally to all residents regardless of race, color, creed, national origin, or payment source.
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for for two of seven sampled residents (Resident 1 & Resident 2). Resident 1 and Resident 2 were observed in the facility ' s surveillance camera recordings having a physical altercation with each other.
This deficient practice affects the safety and well-being of the residents, exposing the residents to physical or mental trauma.
Findings
During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/27/2023 with diagnoses of muscle weakness, unspecified dementia (a decline in mental capacity affecting thought and decision-making tasks), and personal history of transient ischemic attack (a temporary loss of blood flow to a part of the brain).
During a review of Resident 1 ' s Minimum Data Set ([MDS] standardized assessment and care planning tool) dated 8/2/2024, the MDS indicated Resident 1 has severe impairment in thought process.
During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/4/2023 with diagnoses of opioid (a class of addictive drugs) dependence, bipolar disorder (a mental health condition that causes extreme mood swings), and generalized anxiety (the feeling of worry, nervousness, or unease) disorder.
During a Review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 1 was capable of making decision-making tasks.
During a concurrent interview and record review on 8/15/2024 at 4:07 p.m. with the Administrator Assistant (AA), the facility ' s surveillance footage with the recording date and time of 8/7/2024 at 1:44:29 p.m. was reviewed. The AA verified Resident 1 and Resident 2 as the residents in the video surveillance and stated the video showed both residents were in the hallway between Nursing Station A and Nursing Station B. The AA stated Resident 2 was walking and Resident 1 was sitting in wheelchair. The AA stated at 1:44:49 p.m., the video showed Resident 1 tapping (the act or process of striking something with a light blow) the left side of Resident 2 ' s waistline area, then at 1:44:50 p.m., Resident 2 used the his right hand to hit the upper back of Resident 1, with Resident 1 reacting and hitting Resident 2 again, hitting Resident 2 ' s left elbow area. l. The AA stated it is not okay for abuse to happen at the facility. The AA stated that staff are present to protect the residents and make sure the facility is a safe environment for the residents.
During a review of an undated facility provided policy and procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident ' s symptoms.
Aug 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure resident had the right to receive an unopened package for one of five sampled residents (Resident 2). This deficient practice violat...
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Based on interview and record review, the facility failed to ensure resident had the right to receive an unopened package for one of five sampled residents (Resident 2). This deficient practice violated Resident 2's right to receive an unopened package and had the potential to negatively affect the resident's psychosocial wellbeing.
Findings:
During a review of Resident 2's admission Record indicated the facility admitted the resident on 8/8/2024 with a diagnosis of type two diabetes mellitus with hyperglycemia (a chronic condition that occurs when a person with type 2 diabetes has high blood sugar levels)
During a review of Resident 2's Minimum Data Set (MDS- an assessment and care screening tool) dated 8/14/2024 indicated that Resident 2's cognition (mental process) was intact (not damaged).
During an interview on 9/6/2024 at 9:25 a.m., Resident 2 stated not feeling safe in here because they open his package without his permission yesterday (9/5/2024) around 3 p.m Resident 2 further stated he was losing confidence and trust to this place and just wanted to leave.
During an interview on 9/6/2024 at 12:45 p.m., License Vocational Nurse 3 (LVN 3) stated she assumed the package contained medications for Resident 2 to be kept in the medication cart that was why she opened it without Resident 2 present. Then later on, LVN 2 found out that Resident 2 was mad and was looking for his package. LVN 3 stated she informed Resident 2 that the medication was kept in the medication cart.
During an interview on 9/6/2024 at 1:09 p.m., the Director of Nursing (DON) stated it was Resident 2's right to receive an unopened package and next time staff should ask the resident's permission before opening their mail.
During a review of the facility's policy and procedure titled, Mail and Electronic Communication, dated 5/2017, indicated, mail will be delivered to the resident unopened and staff members of the facility will not open mail for the resident unless the resident requests them to do so.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident was not subjected to a physical abuse (delibera...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident was not subjected to a physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for a second time by a resident who was physically abusive for one of three sampled residents (Resident 3). The facility failed to:
1. Ensure Resident 4 did not hit Resident 3 ' s left leg with his (Resident 4) wheelchair on 7/19/2023.
2. Ensure the facility ' s policy and procedures (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, was followed to ensure Resident 3 was free form physical abuse.
This deficient practice resulted in Resident 3 being subjected to physical abuse by Resident 4 while under the care of the facility resulting in Resident 3 ' s left leg pain requiring pain medication.
Findings:
During a review of Resident 3 ' s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including depression (is a common and serious medical illness that negatively affects how you feel, the way you think, and how you act), hypertension ([HTN] high blood pressure), and other abnormalities of gait (manner of walking or moving on foot) and mobility (the ability to move or be moved freely and easily).
During a review of Resident 3's History and Physical, dated 1/06/2024, the History and Physical indicated the resident had the capacity to understand and make decisions.
During a review of Resident 3's Minimum Data Set ([MDS] - a standardized assessment and care-screening tool), dated 7/3/2024, the MDS indicated the resident ' s cognitive skills (ability to understand and make decisions) for daily decision making were intact (not affected). The MDS indicated Resident 3 required supervision or touching assistance for oral hygiene and rolling left and right. The MDS indicated Resident 3 required moderate assistance with upper body dressing, personal hygiene, and substantial/maximal assistance with toileting, shower/bathe, lower body dressing, putting on/taking off footwear, sit lying, lying to sitting on the side of bed, and sit to stand.
During a review of Resident 4 ' s COC, dated 7/4/2024, the COC indicated the Licensed Vocational Nurse (LVN 5) reported that Resident 4 had a physical aggression towards Resident 3.
During a review of Resident 3 ' s COC, dated 7/4/2024, the COC indicated the resident was heard at the Station 2 hallway reporting that he was hit by Resident 4 on the right forehead resulting in two to three pain level on a pain scale from zero to 10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain possible).
During a review of Resident 3 ' s Progress Notes, dated 7/4/2024 timed at 6:04 p.m., the Progress Notes indicated at 3:30 p.m., Resident 3 while seated in a wheelchair, wheeled himself outside Resident 4 ' s room where LVN 5 was with Resident 4. LVN 5 witnessed Resident 3 and Resident 4 talking to each other when Resident 3 tapped Resident 4 ' s right knee and Resident 4 complained of pain and punched Resident 3 ' s right side of the head.
During a review of Resident 3's Change in Condition Evaluation (COC), dated 7/19/2024, the COC indicated Resident 3 reported that Resident 4 kicked Resident 3 ' s left leg and left side of his abdomen on 7/19/2024 in the afternoon (time not indicated). The COC indicated Resident 3 had no signs of injury but complained of moderate pain rated 5 out of 10 in his left leg and asked for pain medication.
During a review of Resident 3 ' s Physician ' s Order Summary Report, dated 12/28/2023, the Physician ' s Order Summary Report indicated an order dated 12/28/2023, for Tylenol tablet 500 milligrams ([mg]- a unit of measure) two tablets for moderate to severe pain rated 5 out of 10 on a pain rating scale.
During a review of Resident 3's Medication Administration Record (MAR), dated 7/19/2024, and timed 5:45 p.m., the MAR indicated the resident received Tylenol 500 mg two tablets for moderate to severe pain rated 5 out of 10 on a pain rating scale.
During a review of Resident 4 ' s admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including depression, hypertension, and personal history of other mental and behavior disorders.
During a review of Resident 4's History and Physical, dated 1/06/2024, the History and Physical indicated the resident had the capacity to understand and make decisions.
During a review of Resident 4's MDS, dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decision making were intact. The MDS indicated Resident 4 required supervision or touching assistance for oral hygiene. The MDS indicated Resident 4 required moderate assistance with upper body dressing, personal hygiene and substantial/maximal assistance with transferring, showering, toileting, and lower body dressing.
During an interview on 8/1/2024 at 11:37 a.m., the Social Services Director (SSD) stated that she talked to Resident 3 on 7/22/2024. The SSD stated Resident 4 was transferred to general acute care hospital 1 (GACH 1) on 7/20/2024 due to aggressive behavior and returned to the facility same day. The SSD also stated that on 7/22/2024, Resident 3 reported to her (SSD) that he (Resident 3) observed Resident 4 going up and down the nurses ' station using his (Resident 4) wheelchair when he (Resident 3) was sitting in front of his (Resident 3) room. Resident 3 stated Resident 4 headed back towards Resident 3 and tried to kick him (Resident 3) with his (Resident 4) raised left leg. Resident 4 ' s wheelchair ended up hitting Resident 3 ' s left leg. The SSD stated staff saw what happened and immediately separated the residents from each other. The SSD also stated Resident 4 was transferred out to GACH 2 on 7/23/2024 due to concerns about Resident 4 ' s cognition and physical aggression.
During an interview on 8/1/2024 at 1:13 p.m., Resident 3 recalled the altercation between him and Resident 4 on 7/19/2024. Resident 3 stated while he was sitting in his wheelchair in the hallway in front of his room, Resident 4 went past him (Resident 3) five times in his (Resident 4) wheelchair and then he (Resident 4) tried to kick him (Resident 3) with his (Resident 4) raised left leg and missed; however, Resident 4 ' s wheelchair hit his (Resident 3) left leg. Resident 3 stated that Resident 4 tried to push his (Resident 3) face, but Licensed Vocational Nurse 1 (LVN 1) immediately came and took Resident 4 to his (Resident 4) room. Resident 3 stated that his left leg hurt after the incident and LVN 1 gave him (Resident 3) Tylenol for the pain and offered him (Resident 3) an ice pack. Resident 3 stated the incident was the second time that Resident 4 had hurt him (Resident 3). Resident 3 stated that he had no injuries to his left leg. Resident 3 stated that he had no interaction with Resident 4 after the incident, and Resident 4 was being monitored by staff continuously. Resident 3 stated that he feels safe in the facility but not when Resident 4 attacked him.
During an interview on 8/1/2024 at 3:23 p.m., LVN 1 stated that on 7/19/2024 at around 5 p.m., Resident 4 was trying to strike out at Resident 3 and she separated the residents. LVN 1 stated she saw Resident 3 was hit in the left leg with Resident 4 ' s wheelchair. LVN 1 stated she gave Resident 3 Tylenol for his left leg pain. LVN 1 stated Resident 3 had no injuries, redness, or skin breakdown. LVN 1 stated that Resident 4 was never hit or kicked by Resident 3 or by anyone. LVN 1 stated that Resident 4 was placed on one-to-one supervision and taken to his room. LVN 1 stated that abuse should never happen in the facility; sometimes it can be hard to prevent, but no resident should be abused in the facility.
During an interview on 8/5/2024 at 12:01 p.m., Resident 3 stated that he needed pain medication for the first three days for his left leg after the incident with Resident 4.
During an interview on 8/5/2024 at 1:19 p.m., the Administrator (ADM) stated the facility ' s job is to protect and prevent abuse from happening to residents and the abuse should not have happened between Resident 3 and Resident 4. The ADM stated that no one should be abused in the facility.
During a review of undated facility ' s P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident ' s symptoms.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention, investigation, and policies and pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention, investigation, and policies and procedures for one out of three sampled residents (Resident 3) by failing to complete a thorough investigation regarding allegations of abuse involving Resident 3.
This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.
Findings:
During a review of Resident 3 ' s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including depression (is a common and serious medical illness that negatively affects how you feel, the way you think, and how you act), hypertension ([HTN] high blood pressure), and other abnormalities of gait (manner of walking or moving on foot) and mobility (the ability to move or be moved freely and easily).
During a review of Resident 3's Minimum Data Set ([MDS] - a standardized assessment and care-screening tool), dated 7/3/2024, the MDS indicated the resident ' s cognitive skills (ability to understand and make decisions) for daily decision making were intact (not affected). The MDS indicated Resident 3 required supervision or touching assistance for oral hygiene and rolling left and right. The MDS indicated Resident 3 required moderate assistance with upper body dressing, personal hygiene, and substantial/maximal assistance with toileting, shower/bathe, lower body dressing, putting on/taking off footwear, sit lying, lying to sitting on the side of bed, and sit to stand.
During a review of Resident 4 ' s admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including depression, hypertension, and personal history of other mental and behavior disorders.
During a review of Resident 4's MDS, dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decision making were intact. The MDS indicated Resident 4 required supervision or touching assistance for oral hygiene. The MDS indicated Resident 4 required moderate assistance with upper body dressing, personal hygiene and substantial/maximal assistance with transferring, showering, toileting, and lower body dressing.
During a review of the facility`s investigation report, dated 7/24/2024, the investigation report indicated on 7/19/2024 at approximately 5:10 p.m., Licensed Vocational Nurse 1 (LVN 1) witnessed Resident 4 in front of Resident 3 and attempting to kick Resident 3 ' s right leg. The investigation report indicated Resident 4's leg hit the left part of Resident 3 ' s wheelchair missing him (Resident 3). The investigation report did not indicate that Resident 4 ' s wheelchair hit Resident 3 ' s left leg. The investigation report did not indicate that Resident 3 needed pain medication after the altercation and did not indicate where the location of Resident 3 ' s injury was.
During an interview on 8/1/2024 at 1:13 p.m., Resident 3 recalled the altercation between him and Resident 4 on 7/19/2024. Resident 3 stated while he was sitting in his wheelchair in the hallway in front of his room, Resident 4 went past him (Resident 3) five times in his (Resident 4) wheelchair and then he (Resident 4) tried to kick him (Resident 3) with his (Resident 4) raised left leg and missed; however, Resident 4 ' s wheelchair hit his (Resident 3) left leg. Resident 3 stated that Resident 4 tried to push his (Resident 3) face, but Licensed Vocational Nurse 1 (LVN 1) immediately came and took Resident 4 to his (Resident 4) room. Resident 3 stated that his left leg hurt after the incident and LVN 1 gave him (Resident 3) Tylenol for the pain and offered him (Resident 3) an ice pack. Resident 3 stated the incident was the second time that Resident 4 had hurt him (Resident 3). Resident 3 stated that he had no injuries to his left leg. Resident 3 stated that he had no interaction with Resident 4 after the incident, and Resident 4 was being monitored by staff continuously. Resident 3 stated that he feels safe in the facility but not when Resident 4 attacked him.
During an interview. on 8/5/2024 at 1:19 p.m., the Administrator (ADM) stated when he interviewed Resident 3, three days after the altercation, he (Resident 3) stated that he did not have any pain. The ADM stated that his 5-day report could have been more concise and clearer and needed to directly address the actual injury that Resident 3 received to his left leg from Resident 4 ' s wheelchair. The ADM stated that he should have asked Resident 3 if the wheelchair hit his leg and should have written in the 5-day report that Resident 3 received pain medication for his left leg.
During a review of the undated facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, indicated the facility ' s policy, The individual conducting the investigation as a minimum reviews the documentation and evidence, reviews all the events leading up to the alleged incident and documents the investigation completely and thoroughly.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Facility failed to ensure that staff followed proper infection control procedures when moving between isolation rooms for two of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Facility failed to ensure that staff followed proper infection control procedures when moving between isolation rooms for two of five sampled residents (Resident 5 and Resident 4). Staff did not remove their used PPE and put on new PPE before entering the isolation room (room [ROOM NUMBER]) of Resident 5 after being in Resident 4's isolation room (room [ROOM NUMBER]). Additionally, the Kitchen Aid (KA 1) threw his used gloves on the residents' coffee cart instead of disposing them in the trash can.
This deficient practice had the potential of spreading infection to other residents.
Findings:
During a review of Resident 4's admission Record indicated the facility admitted the resident on 6/3/2024, with a diagnosis of rhabdomyolysis (a rare, serious, and potentially life-threatening condition that occurs when muscle tissue breaks down and releases its contents into the blood).
During a review of Resident 4's Change of Condition Evaluation, dated 8/30/2024, indicated that Resident 4 had a Covid-19 (mild to severe respiratory illness that is caused by a coronavirus) positive test result.
During a review of Resident 4's physician order summary, dated 8/30/2024, indicated novel respiratory precautions related to positive covid test result every shift for 10 days.
During a review of Resident 5's admission Record indicated the facility admitted the resident on 7/6/2024, with a diagnosis of metabolic encephalopathy (a brain dysfunction that occurs due to a chemical imbalance in the blood that affects the brain).
During a review of Resident 5's Change of Condition Evaluation, dated 9/3/2024, indicated that Resident 5 was Covid-19 positive.
During a review of Resident 5's physician order summary, dated 9/3/2024, indicated novel respiratory precautions related to positive covid-19 test result every shift for 10 days.
During an observation on 9/6/2024 at 9:45 a.m., the KA was observed in the hallway outside Resident 4's room (room [ROOM NUMBER]). The KA was wearing gloves, a gown, a mask, and a face shield. KA removed their soiled gloves and placed them on the coffee cart, then sanitized their hands with a wipe. Subsequently, they put on a new glove, grabbed a coffee, and entered room [ROOM NUMBER].
During an observation on 9/6/2024 at 9:48 a.m., KA was observed in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. The KA was seen exiting room [ROOM NUMBER] while still wearing a glove, gown, mask, and face shield. He then removed his soiled gloves and placed them on the coffee cart, sanitized their hands with a wipe, put on a new glove, grabbed a coffee, and proceeded to enter Resident 5's room (room [ROOM NUMBER]).
During an observation and interview on 9/6/2024 at 9:50 a.m., with KA stated he should throw his gloves in the trash can and not kept it in the coffee cart and removed all my PPE before entering room [ROOM NUMBER]. Because I could spread infection to other residents.
During an interview on 9/6/2024 at 10:06 a.m., the Assistant Director of Nursing (ADON) stated staff must removed PPE before leaving the room and wear a new set of PPE before entering another resident's room.
During a review of the facility's policy and procedure titled, Isolation Initiating Transmission Based Precautions, undated, indicated when transmission-based precautions are implemented, the infection preventionist or designee clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment that must be used.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect residents right to be free from abuse for two of three samp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect residents right to be free from abuse for two of three sampled residents (Resident 1 and Resident 3) by:
1. Failing to ensure Resident 1 was free from physical abuse inflicted by Resident 2. On 7/4/2024 at 3:45 p.m., Licensed Vocational Nurse 1 (LVN 1) witnessed Resident 2 punched Resident 1's right side of the head.
2. Failing to ensure Resident 3 was free from verbal abuse inflicted by Certified Nursing Assistant 2 (CNA 2). On 6/29/2024 at 2:05 a.m., CNA 1 heard CNA 2 telling Resident 3 to shut up and be quiet in a loud voice.
These deficient practices resulted to:
1. Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility.
2. Resident 3 being subjected to verbal abuse by CNA 2 while under the care of the facility.
Based on the Reasonable Person Concept (refers to a tool to assist the team 's assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident's position), due to Resident 3's impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering), skills and medical condition, an individual subjected to abuse may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for own self).
Findings:
a. A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 12/27/2023 with diagnoses that included diabetes mellitus (uncontrolled elevated blood sugar), muscle weakness, and unspecified (unconfirmed) depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities).
A review of Resident 1's History and Physical (H&P), dated 1/6/2024, indicated Resident 1 had capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/3/2024, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.
A review of Resident 1's Change in Condition (CIC) Evaluation, dated 7/4/2024, indicated Resident 1 was heard at the Station 2 hallway reporting that he (Resident 1) was hit by Resident 2 on the right forehead with two to three level of pain out of 10 (0- no pain and 10 severe pain).
A review of Resident 1's Progress Notes, dated 7/4/2024 timed at 6:04 p.m., indicated at 3:30 p.m., Resident 1 seated in a wheelchair, wheeled himself outside Resident 2's room where LVN 1 was with Resident 2. LVN 1 witnessed Resident 1 and Resident 2 talking to each other when Resident 1 tapped Resident 2's right knee and Resident 2 complained of pain and punched Resident 1's right side of the head.
A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 8/26/2020 with diagnoses that included diabetes mellitus, absences of left leg below knee and depression.
A review of Resident 2's H&P, dated 1/6/2024, indicated Resident 2 had capacity to understand and make decisions.
A review of Resident 2's MDS, dated [DATE], indicated resident's cognitive skills for daily decisions was intact.
A review of Resident 2's CIC, dated 7/4/2024 indicated, at 3:45 p.m., LVN 1 reported that Resident 2 had physical aggression towards Resident 1.
During an interview on 7/10/2024 at 10:27 a.m., Resident 1 stated he went outside in the hallway to get his medication from LVN 1 when Resident 2 hit him on the right head.
During an interview on 7/18/2024 at 10:37 a.m., LVN 1 stated he was preparing the medication in front of Resident 2's room when Resident 1 came and asked for his medication. LVN 1 stated he heard Resident 1 and Resident 2 talking in another language when Resident 1 tapped Resident 2's right knee. LVN 1 stated Resident 2 then complained of pain and hit Resident 1's right side of the head using Resident 2's right hand. LVN 1 stated Resident 1 did not complain of pain. LVN 1 stated Resident 2 physically abused Resident 1.
During an interview on 7/18/2024 at 11:09 a.m., the Assistant Director of Nursing (ADON) stated the incident between Resident 1 and Resident 2 was witnessed by LVN 1 and was a physical abuse.
During an interview on 7/18/2024 at 11:19 a.m., the Administrator (ADM) stated LVN 1 witnessed Resident 2 physically hit Resident 1 in the right side of the head.
b. A review of Resident 3's admission Record indicated the facility admitted Resident 3 on 10/25/2016 with diagnoses that included Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), diabetes mellitus and unspecified dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
A review of Resident 3's H&P, dated 1/13/2024, indicated Resident 3 did not have the capacity to understand and make decisions.
A review of Resident 3's MDS, dated [DATE], indicated resident's cognitive skills for daily decisions was severely impaired. The MDS indicated Resident 3 had verbal behavior symptoms directed at others (example given screaming at others, cursing at others).
A review of Resident 3's CIC, dated 6/29/2024, indicated CNA 1 heard CNA 2 telling Resident 3 to shut up and be quiet in a loud tone of voice.
A review of Resident 3's Progress Notes, dated 6/29/2024 timed at 6:10 a.m., indicated on 6/29/2024 at 2:05 a.m., heard a scream from Resident 3's room. LVN 2 went to Resident 3's room and noticed CNA 1 walked out of the room. LVN 1 heard CNA 2 telling Resident 3 to be quiet in a loud tone at least twice. LVN 1 removed CNA 2 from Resident 3's room and CNA 2 was sent home.
A review of Resident 3's Abuse Investigation Report Form, dated 6/29/2024, indicated at 2:05 a.m., CNA 2 verbally insulted and bad-mouthed Resident 3.
A review of Resident 7's admission Record indicated the facility admitted Resident 7 on 3/18/2024 with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), dementia and anxiety (a feeling of fear, dread, and uneasiness).
A review of Resident 7's MDS, dated [DATE], indicated Resident 7's cognitive skills for daily decision were severely impaired.
A review of Resident 8's admission Record indicated the facility admitted Resident 8 on 9/12/2018 with diagnoses that included morbid obesity (weight is more than 80 to 100 pounds above their ideal body weight) due to excess calories, lymphedema (occur when lymph vessels or nodes become damaged or blocked, which affects the flow of lymph in the body) and cellulitis (potentially serious bacterial skin infection which the affected skin is swollen and inflamed and is typically painful and warm to the touch) of unspecified part of limb (arm or leg).
A review of Resident 8's MDS, dated [DATE], indicated Resident 8's cognitive skills for daily decision were intact.
During an interview on 7/10/2024 at 10:51 a.m., the Director of Staff Development (DSD) stated CNA 2 was hired on 6/13/2024. The DSD stated he (DSD) was informed by Director of Nursing (DON) of alleged (accused but not proven) verbal abuse on 6/29/2024 by CNA 2 to Resident 3. The DSD stated CNA 1 confirmed CNA 2 said shut up to Resident 3. The DSD stated CNA 2 was suspended from 6/29/2024 and resigned on 7/2/2024. The DSD stated he did not report CNA 2 to the Board of Nursing because he believed it was not necessary.
During an interview on 7/10/2024 at 12:09 p.m., the ADM stated CNA 1 heard CNA 2 said shut up to Resident 3. The ADM stated he (ADM) cannot determine if it was a verbal abuse. ADM stated the language was not appropriate and residents should not be treated that way.
During an interview on 7/18/2024 at 9:06 a.m., CNA 2 stated on 6/28/2024 he worked double shift from 3 p.m. to 11 p.m. then from 11 p.m. until 6/29/2024 at 7 a.m. in Station 4. CNA 2 stated on 6/28/2024 from 11 p.m., Resident 3 made a lot of sound inside the room. CNA 2 stated on 6/29/2204 at 2 a.m., Resident 3 was talking to herself, and Resident 7 was disturbed and banging on the side rail. CNA 2 stated the banging was so loud that it can be heard even when Resident 3 and Resident 7's door was close. CNA 2 stated he was inside Resident 3's room many times to tell Resident 3 to stop talking. CNA 2 admitted he (CNA 2) told Resident 3 to shut up. CNA 2 stated Resident 3 cannot hear and would not listen, so he spoke in elevated voice telling Resident not to talk. CNA 2 stated saying shut up was harsh and should have said do not talk instead. CNA 2 stated Resident 7 was disturbed, and Resident 3 had to respect the other residents in the room. CNA 2 stated while he was talking to Resident 3, CNA 1 came in brought water followed by LVN 2. CNA 2 stated when LVN 2 went inside the room, LVN 2 told CNA 2 not to talk to Resident 3 that way. CNA 2 stated LVN 2 told CNA 2 to go home.
During an interview on 7/18/2024 at 10:27 a.m., LVN 2 stated on 6/29/2204 at 2 a.m., LVN 2 heard a commotion (noisy disturbance) in Resident 3 and Resident 7's room. LVN 2 stated as he (LVN 2) went to the room, saw CNA 1 came out then heard CNA 2 told Resident 3 to be quiet in a loud voice while CNA 2 was standing beside Resident 3. LVN 2 stated he stopped CNA 2 and informed him of resident's rights to be loud and to talk. LVN 2 stated CNA 2 was sent home and reported the incident to DON and ADM. LVN 2 stated CNA 1 reported that she (CNA 1) heard CNA 2 said shut up to Resident 3. LVN 2 stated he did not think it was a verbal abuse, but he (LVN 2) sent CNA 2 home to protect the residents from CNA 2.
During an interview on 7/18/2024 at 11:09 a.m., the ADON stated CNA 2 verbally abused Resident 3.
During an interview on 7/18/2024 at 11:19 a.m., the ADM stated he (ADM) treated the incident between Resident 3 and CNA 2 as abuse.
During an interview on 7/18/2024 at 1:13 p.m., Resident 8 (Resident 3's roommate) stated on 6/29/2024 early morning, CNA 2 had been in and out of the room telling Resident 3 to shut up. Resident 8 stated CNA 2 also said derogatory words and CNA 2 was louder than Resident 3 and Resident 7 combine. Resident 8 stated she thought CNA 2 would hit Resident 3 because CNA 2 also pointed his (CNA2) finger on Resident 3. Resident 8 stated she (Resident 8) heard CNA 2 said shut up, be quiet and used derogatory word multiple times.
A review of facility's policy and procedure (PnP) titled, Abuse, Neglect (fail to care for properly), Exploitation (treating someone unfairly) and Misappropriation Prevention Program, undated, indicated, Resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment (the infliction of physical pain upon a person's body as punishment for a crime), involuntary seclusion (separation of a resident from other residents or from her/his room or confinement to her/his room against the resident's will), verbal, mental, sexual or physical abuse and physical or chemical restraint (the act of holding something back) not required to treat the residents' symptoms Protect resident from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to a. facility staff, b. other residents .
A review of facility's PnP titled, Abuse and Neglect-Clinical Protocol, dated 3/2018, indicated, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. ''Willful, as defined as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
Jun 2024
10 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · 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 six sampled residents (Resident 1), who was cognitive...
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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 six sampled residents (Resident 1), who was cognitively (mental action or process of acquiring knowledge and understanding) intact and had a history of right-sided weakness following a cerebral infarction (stroke-a loss of blood flow to part of the brain, which damages brain tissue), was free from sexual abuse (sexual behavior or a sexual act forced upon a woman, man, or child without their consent). On 5/26/2024 at 8:45 p.m., Certified Nursing Assistant 2 (CNA 2) and CNA 3, after hearing Resident 1 yelling for help, went to Resident 1 ' s room. CNA 2 and CNA 3 witnessed Resident 2, Resident 1 ' s roommate, on top of Resident 1 and was kissing Resident 1 ' s neck area. Resident 1 was lying in his bed with both feet on the floor and Resident 2 was pulling Resident 1 ' s jeans down to his knees. Resident 1 told CNA 2 and CNA 3 to separate Resident 2 off him because Resident 2 was kissing and touching him (Resident 1). When CNA 2 and CNA 3 separated Resident 2 from Resident 1, Resident 2 ' s hands were still holding Resident 1 ' s jeans.
As a result, Resident 1 was subjected to a nonconsensual (without permission) sexual abuse by Resident 2 while under the care of the facility. CNA 2 stated Resident 1 was yelling, his face and body were shaking, trying not to cry, and looked nervous (having or showing feelings of being worried and afraid about what might happen). CNA 3 stated Resident 1 was found trying to get up and fight Resident 2, but Resident 1 cannot move his right arm. Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 appeared in shock (person's emotional and physical condition when something very frightening or upsetting has happened to them), shaking, hyperventilating (rapid or deep breathing, usually caused by anxiety [a feeling of fear, dread, and uneasiness] or panic [painful agitation in the presence or anticipation of danger] and was at a loss for words when she went to Resident 1 ' s room following CNAs 2 and 3.
On 6/4/2024 at 11:22 a.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of Director of Nursing (DON) and Payroll Staff 1 (PS 1) due to the facility ' s failure to prevent the sexual abuse to Resident 1.
On 6/7/2024 at 12:34 p.m., the Administrator (ADM), provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings).
On 6/7/2024 at 2:24 p.m., while onsite and after verifying the facility ' s full implementation of IJ Removal Plan through observation, interview, and record review, the SSA removed the IJ situation in the presence of the DON, Assistant Director of Nursing (ADON), Director of Staff Development (DSD) and PS 1.
The acceptable IJ Removal Plan included the following summarized actions:
1. On 5/26/24 at around 9 pm, LVN 1 responded and helped CNA 2 and CNA 3 separate Resident 2 from Resident 1. LVN 1 stayed with Resident 1 inside the room to provide emotional support to ensure safety. Resident 2 was removed from the room and placed in the hallway near the nurse's station away from other residents and was provided with one CNA assigned to Resident 2 and three other residents.
2. On 5/26/2024, Registered Nurse 1 (RN 1) assessed Resident 1 with no physical injury, denied any pain and no skin discoloration.
3. On 5/26/2024 at around 9 p.m., RN 1 notified the Medical Doctor (MD). LVN 1 called 911 (an emergency number if in need of any police, fire, or medical response) at around 9:43 p.m. The paramedics (health professionals certified to perform advanced life support procedures) and police officers arrived at the facility at 9:58 p.m. and spoke to Resident 1 and offered to go to the hospital for further support and evaluation, however, Resident 1 refused three times.
4. On 5/26/24 at around 10 pm, two police officers came to the facility to investigate the situation. The police officers suggested calling county Psychiatric (branch of medicine that deals with mental, emotional or behavior disorder) Emergency Team (PET- are mobile teams operated by psychiatric hospitals approved by the Department of Mental Health (DMH) to provide 5150 [ law code that lets adults be involuntary held in a mental hospital for 72 hours] and 5585 [allows involuntary detainment of a minor experiencing a mental health crisis for a 72-hour]. Team members are licensed mental health clinicians to evaluate the resident).
5. On 5/27/2024 at 12:02 a.m., RN 1 called PET team and spoke to the DMH operator who stated they will discuss and will call the facility back. At around 7:30 a.m., the DMH called and informed RN 2 that they will evaluate Resident 2 at the facility.
6. On 5/26/2024 at 11:56 p.m., RN 1 initiated an order to monitor Resident 1 every shift for psychological (concerned with a person's mind and thoughts) and emotional status. On 6/7/2024, Quality Assurance Nurse (QAN) clarified monitoring order that Resident 1 will be monitored for emotional and psychosocial indicators such as sudden or unexplained changes in behavior and or activities example fear or avoidance of a person or place, fear of being alone, fear of the dark, nightmares, disturbed sleep, verbalization of sadness, decrease appetite, restlessness, episodes of crying, change in daily routine. The care plan about monitoring for psychological and emotional behavior was initiated for Resident 1 on 5/27/24 by the RN 1 and updated by QAN on 6/7/24.
7. On 5/26/2024, RN 1 initiated the investigation and interviewed the two CNA witnesses and LVN 1.
8. On 5/26/2024 at 10 p.m., Resident 2 was closely monitored by nursing staff until he was transferred to the General Acute Care Hospital 1 (GACH 1) psychiatric unit on 5/27/24 at 11 am. Resident 2 stayed in his wheelchair, mostly in the hallway near the nurse's station the entire night shift and in the morning shift, RN 2 watched him in front of the nurse ' s station at the start of the shift. Patio Staff Attendant 1 (PSA 1) supervised Resident 2 at the smoking patio from 8:30 a.m. until he was brought to the family room to be evaluated by the DMH staff. Resident 2 was attended to by the activity staff in the activity room awaiting pick-up by paramedics for GACH 1 transfer.
9. On 5/27/2024 at 8:30 a.m., the DMH evaluated and found Resident 2 qualified for a psychiatric hold (a legally mandated stay at a psychiatric facility aimed at providing a safe space and professional care to those going through a mental health crisis). The DMH set up transportation and Resident 2 was picked up by paramedics and taken to GACH 1 Psychiatric Unit emergency room at 11 a.m. Resident 2 was seen by the Psychiatrist Doctor (medical practitioner specializing in the diagnosis and treatment of mental illness) with modification of medications and was deemed stable to return to facility on 5/28/24.
10. On 5/28/2024, Resident 2 returned to the facility and his psychoactive medications (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) were modified to the following:
a. Haloperidol (used to treat certain mental or mood disorders) tablet five milligrams (mg - unit of measurement), give one tablet by mouth two times a day for schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) manifested by outburst (sudden release of strong emotion) of anger.
b. Trazodone hydrochloride (used to improve your mood, appetite, and energy level) tablet 50 mg, give half tablet by mouth at bedtime for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) manifested by inability to sleep.
11. On 5/28/2024 at 3:25 p.m., upon return from GACH 1, Resident 2 was monitored by licensed nursing staff of his behavioral status and whereabouts of every shift. On 6/4/2024 from 3 p.m., Resident 2 was placed on closer visual checks and monitoring of whereabouts every two hours by both LVN and CNA assigned.
12. On 6/6/2024, Resident 2 had an order for behavioral monitoring to include monitoring for any signs and changes in behavior, mood, cognition, hallucinations (to seem to see, hear, feel, or smell something that does not exist, usually because of a health condition or because you have taken a medication), delusions (a person with a delusion believes something that is not true no matter how much evidence you give to the contrary), social isolation (lack of social contacts and having few people to interact with regularly), suicidal thoughts (involve a person thinking about ending their own life), withdrawal (not finishing an activity), and decline in activities of daily living. The ADON updated Resident 2 ' s care plan on 6/6/24.
13. The Social Service Director (SSD) conducted psychosocial (relating to the mutual relationship of social factors and individual thought and behavior) visits to Resident 1 on 5/28/24, 5/29/24, 5/30/24, and as needed.
14. On 5/30/2024, the Psychologist Doctor (a person who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) saw Resident 1 who denied any issues with any other residents and appeared to not be aware of what the Psychologist was referring to as the subject of unwanted contact by another resident. Resident 1 stated that he had no issues or concerns related to other residents.
15. On 6/3/2024, the Psychiatrist Doctor (a medical doctor who specializes in psychiatry. They treat people with mental illness) saw Resident 1 who stated he had persistent losses that contributed to his feelings of sadness and denied any recent physical or sexual abuse by another resident. Resident 1 was started on Lexapro (used to treat certain mental or mood disorders) five mg by mouth every morning.
16. On 5/28/2024, the DON and Director of Staff Development (DSD) provided an in-service about sexual abuse to staff; CNA ' s, LVN ' s, RN ' s, Rehabilitation Department, housekeeping staff, activity staff, maintenance staff, kitchen staff, and laundry staff.
17. The Department Managers, as part of their daily quality initiative rounds, conducted rounds for safety and observations of any reports of sexual abuse with interviews to identify and address any concerns on 5/28/24, 5/29/24, 5/30/24, 5/31/24, 6/3/24, and 6/4/24. No safety issues were identified, and residents did not mention anything related to abuse or sexual allegations.
18. On 6/4/2024, the Department Managers conducted interviews to alert residents in their assigned resident rounds to identify any abuse or sexual allegations. The SSD conducted full facility rounds to screen all residents in-housed on 6/04/2024 and no concerns of any forms of abuse were identified.
19. On 5/28/2024, the DON and DSD provided in-services and interaction with staff on Abuse Prevention Program specific to sexual abuse to facility staff and identified no other resident involved during in-service discussion.
20. The DSD continued providing in-services to all staff: CNAs, LVNs, RNs rehabilitation department, housekeeping staff, activity staff, maintenance staff, kitchen staff and laundry staff that was started on 5/28/2024 and had 65 percent (% - the symbol used to indicate a percentage, a number or ratio as a fraction of 100) of active staff attendees and will continue to educate active staff members to achieve a minimum of 80% of active employees by 6/6/2024 and 100% by 6/7/2024. Any employee that was on per diem (a flexible work arrangement where employers employ individuals on an as-needed basis, often in temporary or part-time roles), part time or had missed the in-services will be trained in advance of their scheduled date or upon arrival prior to working on the floor.
21. On 6/4/2024, the Department Managers conducted daily quality initiative rounds for safety and observation of any report of sexual abuse and as a part of the rounds will interview current residents with capacity to be interviewed daily.
22. LVNs and RNs will prompt staff at shift huddles with CNAs to identify any reported allegation of abuse every shift.
23. During weekends, the Manager of the Day (MOD) will ensure that nursing staff will continue to monitor the whereabouts of any resident placed on behavior monitoring. The MOD will do frequent rounds to check if there are any residents with concerns of unwanted contact by other residents. The MOD will ensure completion of the MOD tool and report any negative findings to the ADM or DON timely.
24. Any negative findings during room round monitoring and shift huddles will be reported immediately to the ADM or DON and will conduct investigation appropriately and report the matter to appropriate agencies (local police, long term care Ombudsman [assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences], and SSA) in conjunction with the abuse reporting policies and procedures.
25. The ADM will report any negative findings and/or concerns related to any allegation of abuse involving residents. Any follow-up needed will be reported to the monthly Quality Assurance and Performance Improvement (QAPI - a process used to ensure services are meeting quality standards and assuring care reaches a certain level) Committee for additional recommendations.
26. The QAPI Committee will evaluate weekly the implementation of the plan of correction including room rounds, daily observation of the residents, monitor for effectiveness and revise care plan as necessary for continuous improvement until the resolution is achieved.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/12/2018 with diagnoses that included end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest with symptoms including shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]), hemiplegia (the loss of the ability to move on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant (preference to use one side of the body over the other) side, and anxiety disorder (persistent and excessive worry that interferes with daily activities).
A review of Resident 1 ' s Preadmission Screening and Resident Review (PASRR - screening to identify if resident had mental illness or an intellectual or developmental disability), dated 2/8/2023, indicated Resident 1 had no mental illness.
A review of Resident 1 ' s History and Physical (H&P), dated 1/2/2024, indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1 ' s Trauma Informed Care form, dated 4/16/2024, indicated sexual assault and other unwanted or uncomfortable sexual experience did not apply to Resident 1.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 4/18/2024, indicated Resident 1 needed maximum assistance from staff for lower body dressing (ability to dress and undress below the waist), bed mobility from sitting to standing, and walking. The MDS indicated Resident 1 was occasionally incontinent (unable to control) of bowel and bladder functions.
A review of Resident 1 ' s Psychologist Note, dated 5/13/2024, indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding).
A review of the Physician ' s Order of Resident 1, dated 5/26/2024 timed at 9 p.m., indicated an order to monitor Resident 1 for signs and symptoms of emotional and psychological distress after incident with Resident 2.
A review of Resident 1 ' s Change in Condition Evaluation (COC), dated 5/27/2024, indicated that on 5/26/2024, Resident 2 was found on top of Resident 1. The COC indicated Resident 1 denied pain and had no bruising. The COC indicated the Attending Physician (AP) was notified on 5/26/2024 at 9 p.m. and ordered to assess Resident 1 emotionally and psychologically. The COC indicated the paramedics arrived at 9:45 p.m., but Resident 1 refused to be transferred to the emergency room.
A review of Resident 1 ' s Progress Note dated 5/26/2024 timed at 10:47 p.m., indicated RN 1 was notified about the alleged sexual aggression between Resident 1 and Resident 2. The Progress Note indicated Director of Nursing (DON), Administrator (ADM), and local law enforcement (Police officers) were notified. The COC indicated Resident 2 was placed on one-to-one staff monitoring.
A review of Resident 1 ' s Progress Note, dated 5/27/2024 timed at 00:14 a.m., indicated LVN 1 responded to a sound of verbal altercation (loud argument) on 5/26/2024 at 9 p.m., from Resident 1 and Resident 2 ' s room. The Progress Note indicated LVN 1 saw CNA 2 removing Resident 2 on top of Resident 1 while Resident 1 was in his bed. The Progress Note indicated CNA 2 and CNA 3 reported that Resident 2 was groping and kissing Resident 1. The Progress Note also indicated that Resident 1 reported that Resident 2 was on top of Resident 1 touching him and kissing him non-consensually. The Progress notes indicated LVN 1 had Resident 2 removed from the room and placed on one-to-one staff monitoring. The Progress Note indicated LVN 1 observed Resident 1 shaking. The Progress Note indicated MD, ADM, DON, and ADON was notified. The Progress Note indicated 911 was called, police officers and paramedics arrived but Resident 1 refused to be transferred out and refused to report anything to the police officers.
A review of Resident 1 ' s Physicians Order, dated 5/27/2024 timed at 7:30 a.m., indicated an order for Psychology (the scientific study of the mind and behavior) consult.
A review of Resident 1 ' s Progress Note, dated 5/27/2024 timed at 2:04 p.m., indicated LVN 4 documented that Resident 1 had been in bed sleeping all morning from having no sleep from the night before.
A review of Resident 1 ' s Physician ' s Order, dated 5/27/2024 timed at 5:04 p.m., indicated an order for Psychiatry (branch of medicine concerned with the study, diagnosis, and treatment of mental illness) evaluation and treatment as needed related to Resident 2 kissing and found on top of Resident 1.
A review of Resident 1 ' s Care Plan on at risk for emotional and psychological distress related to Resident 2 kissing and found on top of Resident 1, dated 5/27/2024, indicated an intervention to recognized nonverbal cues (the process of sending information through ways that do not require the use of language) for behavioral and or psychological change.
A review of Resident 1 ' s Restorative Nursing Assistant (RNA) Program indicated, on 5/27/2024, Resident 1 refused passive range of motion (someone physically moves or stretches a part of your body) to right lower extremity (the part of the body that includes the hip, thigh, knee, leg, ankle, and foot).
A review of Resident 2 ' s H&P, dated 1/2/2024, indicated Resident 2 can make needs known but cannot make medical decisions.
A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 2 needed supervision from staff for walking and transfers.
A review of Resident 2 ' s COC Evaluation, dated 5/26/2024, indicated Resident 2 was found on top of Resident 1. The COC indicated on 5/26/2024 at 9 p.m., LVN 1 responded to sound of verbal altercation coming from Resident 1 and Resident 2 ' s room. The COC indicated LVN 1 saw CNAs 2 and 3 removing Resident 2 on top of Resident 1. CNA 2 reported to LVN 1 that Resident 2 was on top groping and kissing Resident 1. The COC indicated Resident 1 stated Resident 2 was touching and kissing him non consensually. The COC indicated MD was notified at 9 p.m. and Family Member 2 (FM 2) was notified at 10 p.m.
A review of Resident 2 ' s Progress Note, dated 5/26/2024, indicated at 9 p.m., LVN 1 responded to sound of verbal altercation and saw CNAs 2 and 3 removing Resident 1 on top of Resident 2. LVN 1 had Resident 2 removed from the room and placed on one-to-one monitoring. The Progress Note indicated MD was notified and ordered 5150 and to call the police. The Progress Note indicated the police arrived at 10 p.m. and police suggested to call the county PET team. The Progress Note indicated Resident 1 was on continued one-to-one monitoring by CNA and endorsed to the next shift to coordinate and maintain one-to-one observation by CNA.
A review of the Physician ' s Order of Resident 2, dated 5/27/2024, indicated the following orders:
a. Department of Mental Health Evaluation after an incident with Resident 1.
b. Transfer to GACH 1 Psychiatry Unit Emergency Room.
During an interview on 5/28/2024 at 3:31 p.m., Resident 1 stated on 5/26/2024 at 9 p.m., he was taking a nap when he woke up and saw Resident 2 wanting to kiss and tried to rub him. Resident 1 stated Resident 2 jumped on Resident 1 ' s bed and tried to take Resident 1 ' s pants out. Resident 1 stated he did not give permission for Resident 2 to touch and kiss him. Resident 1 stated Resident 2 wanted to take his (Resident 1 ' s) pants off.
During an interview on 5/28/2024 at 3:42 p.m., RN 1 stated on 5/26/2024 between 9 p.m., to 10 p.m., she was in Station C when she was paged to Resident 1 and Resident 2 ' s room. RN 1 stated she saw CNA 2, CNA 3, and LVN 1 inside Resident 1 ' s room. RN 1 stated she saw Resident 1 in his bed and Resident 2 outside the room with LVN 5. RN 1 stated LVN 1 reported that CNA 2 and CNA 3 heard Resident 1 screaming and found Resident 2 on top of Resident 1. RN 1 stated Resident 1 reported that he was getting ready to sleep when Resident 2 approached him, went to his bed, and tried to go on top of him. RN 1 stated she reported the incident to the ADM, called police, and called 911. RN 1 stated she assessed Resident 1 and had no pain, no injury, and no bruising. RN 1 stated police officers came but Resident 1 do not want to discuss the incident and refused to answer the questions from the police officers. RN 1 stated Resident 2 stayed up all night, did not want to go to his room and was placed on one-to-one monitoring. RN 1 stated LVN 5 stayed with Resident 2 from 10 p.m., until 11 p.m., then CNA 10 watched Resident 2.
During an interview on 5/28/2024 at 4:13 p.m., LVN 1 stated on 5/26/2024 at 8:45 p.m., to 9 p.m., she was in Station A hallway passing medications when she heard sound of verbal altercation and found CNA 2 and CNA 3 beside Resident 1 who was lying in his bed who appeared to be in shock. LVN 1 stated Resident 2 was just separated from Resident 1 and placed back on a wheelchair beside his bed. LVN 1 stated as she was walking towards Residents 1 and 2 ' s room, CNA 2 reported that Resident 2 was on top of Resident 1, kissing and rubbing Resident 1 in bed. LVN 1 stated Resident 1 reported that it was nonconsensual, he was yelling for help because Resident 2 was on top of him, touching him and Resident 1 do not want to be touched. LVN 1 described Resident 1 to be in shock as Resident 1 was shaking, hyperventilating, and loss for words. LVN 1 stated the incident was nonconsensual because Resident 1 was yelling and did not give consent. LVN 1 stated Resident 2 sexually abused Resident 1.
During an interview on 5/28/2024 at 4:30 p.m., CNA 2 stated on 5/26/2024 at 8:45 p.m., she and CNA 3 were making their rounds in Station A when she heard somebody yelling for help in Spanish. CNA 2 stated she saw Resident 1 laying in the bed with his feet on the floor by the left side of the bed, Resident 1 ' s jeans was down to his knees, incontinent brief open on the right side, Resident 1 ' s face and body was shaking and about to cry. CNA 2 stated she saw Resident 2 on top of Resident 1 and kissing Resident 1 ' s neck area. CNA 2 stated Resident 1 reported that Resident 2 was kissing and touching him. CNA 2 stated as she was trying to separate Resident 2, Resident 2 touched Resident 1 again in the right hip. CNA 2 stated Resident 1 reported that he feared Resident 2. CNA 2 stated she had known Resident 1 for three years and that he was a strong person but that time he looked like he wanted to cry.
During an interview on 5/28/2024 at 5:01 p.m., RN 1 stated based on Resident 1 ' s report, the incident was nonconsensual.
During an interview on 5/28/2024 at 5:15 p.m., Resident 2 stated he touched Resident 1 ' s tummy (abdomen) but denied pulling Resident 1 ' s pants down. Resident 2 stated he did not know why he got closer to him and stated he did not ask permission to get close and touch him. Resident 2 stated he did not think of asking permission to touch Resident 1.
During an interview on 5/29/2024 at 8:08 a.m., CNA 3 stated on 5/26/2024 at around 8:45 p.m., CNA 2 and CNA 3 were doing their last rounds when she heard Resident 1 yelling for help in Spanish and heard a whistling sound. CNA 3 stated she saw Resident 1 in bed trying to get up and trying to fight Resident 2 who was on top of Resident 1, but he cannot move his right arm. CNA 3 stated she saw Resident 2 trying to pull down Resident 1 ' s pants. CNA 3 stated Resident 1 was shaking, looked nervous, scared and Resident 1 saying he did not want Resident 2 in his room. CNA 3 stated when Resident 2 saw CNA 2 and CNA 3 in the room, CNA 3 saw Resident 2 dropped himself and sat on the floor while still holding onto Resident 1 ' s pants. CNA 3 stated, CNA 2 and CNA 3 pulled Resident 2 away from Resident 1. CNA 3 stated Resident 2 walked back to his wheelchair on his side of the bed and wheeled himself out. CNA 3 stated Resident 2 abused Resident 1 because Resident 1 did not allow Resident 2 to touch him.
During an interview on 5/29/2024 at 11:24 a.m., Restorative Nursing Assistant 1 (RNA 1) stated she noticed that Resident 1 gets more upset since Monday, 5/27/2024, and refused to walk and shower on 5/27/2024. RNA 1 stated Resident 1 was quieter since 5/27/2024. RNA 1 stated she felt like what happened on Sunday, 5/26/2024, could have affected Resident 1 ' s behavior, regarding refusal of shower and exercises, and wanting to be alone. RNA 1 stated Resident 1 loves coffee and on the morning of 5/29/2024, RNA 1 did not see Resident 1 attending the activity for coffee social.
During an interview on 5/29/2024 at 11:36 a.m., the Activity Director (AD) stated Resident 1 likes attending all activities especially outdoor exercises and coffee social. The AD stated on 5/27/2024, Resident 1 did not attend the coffee social.
During an interview on 5/29/2024 at 12:15 p.m., the AD stated Resident 1 did not attend any activity on 5/27/2024.
During an interview on 5/29/2024 at 12:16 p.m., the ADON stated based on the report she received from RN 1, Resident 2 sexually abused Resident 1. The ADON stated as of 5/29/2024, Resident 1 was not yet seen by Psychologist and Psychiatrist. The ADON stated it is important for Resident 1 to be seen by the Psychologist and Psychiatrist because of the possible trauma that may cause depression. The ADON stated Resident 1 may get scared and feel not safe with his roommates.
During an interview on 5/29/2024 at 12:27 p.m., the DON defined abuse as willful intent (means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm) to cause harm to another person. The DON stated it is only willful if the resident was alert and oriented, cognitively intact and no diagnoses of dementia and schizophrenia. The DON stated Resident 1 was sexually abused by Resident 2 because it was nonconsensual, because Resident 1 was harassed by Resident 2.
During an interview on 5/30/2024 at 10:20 a.m., CNA 2 stated on 5/26/2024 at 8:45 p.m., she saw Resident 1 in his bed with legs on the floor, Resident 1 ' s jeans were down to just above the knees, Resident 2 was on the left side of Resident 1 ' s bed with Resident 2 was almost kneeling, and his body was on top of Resident 1. CNA 2 stated Resident 2 ' s head was on Resident 1 ' s chest and Resident 2 ' s face was close to Resident 1 ' s neck. CNA 2 stated she worked double shift that day from 5/26/2024 at 3 p.m., until 5/27/2024 at 7 a.m., CNA 2 stated Resident 1 did not sleep the night of 5/26/2024. CNA 2 stated that usually in the morning when she brings the breakfast tray, Resident 1 would be asleep but that morning on 5/27/2024 Resident 1 was awake, refused to shower and appeared to be mentally affected because he did not want to speak to anybody and stayed outside most of the day separated from other residents.
During an interview on 5/30/2024 at 10:54 a.m., CNA 3 stated she saw Resident 2 on top of Resident 1, Resident 2 ' s face was on Resident 1 ' s neck, Resident 1 ' s pants was down to his knees. CNA 3 stated when Resident 2 saw CNA 2 and CNA 3 entering in the room, Resident 2 slid himself down to the floor from Resident 1 ' s top while still pulling down the pants of Resident 1. CNA 3 stated she saw Resident 1 ' s face pale and was shaking.
During an interview on 5/30/2024 at 11:27 a.m., LVN 6 stated Resident 1 was not yet seen by Psychologist and Psychiatrist. LVN 1 stated Resident 1 was scheduled to be seen by Psychologist on 5/31/2024. LVN 1 stated she attended an in-service for abuse after the incident and it was about abuse in general and not about sexual abuse.
During a concurrent interview and record review on 5/30/2024 at 11:55 a.m., with the ADM, facility ' s policy, and procedure (PnP) titled, Identifying Sexual Abuse and Capacity to Consent, dated 9/2022, was reviewed. The facility ' s PnP indicated Sexual abuse is a nonconsensual sexual contact of any type with a resident, as defined at 42 Code of Federal Regulations (CRF) 483.5. Sexual Abuse includes but is not limited to a. unwanted intimate touching of any kind .Generally sexual contact is non-consensual if the resident either; a. appears to want the contact to occur but lacks the cognitive ability to consent or b. does not want the contact to occur. The ADM stated on 5/26/2024 there was a loud commotion in Resident 1 and Resident 2 ' s room and CNA 2 and CNA 3 found Resident 2 on top of Resident 1 attempting to kiss and grope Resident 1. The ADM stated Resident 2 was placed on one-to-one staff monitoring. The ADM stated Resident 1 reported nothing had happen. The ADM stated there was no foul play (unfair dealing) and it was not an abuse. The ADM stated definition of abuse is willful act. The ADM stated Resident 2 not having the capacity and not in his right mind had no willful intent to harm. The ADM stated their policy for sexual abuse defines sexual abuse as nonconsensual sexual contact with a resident. The ADM stated Resident 2 did not sexually abuse Resident 1 because Resident 2 was not in his right mind due to diagnosis of dementia and schizophrenia. The ADM stated if somebody does not have the capacity then they do not have the capacity to make act willful. The ADM stated based on the report he received, Resident 1 did not agree to have consensual contact.
A review of Resident 1 ' s Psychological Consultation, dated 5/30/2024, indicated the consultation was requested by the facility about a report of Resident 1 being kissed by Resident 2 without consent from Resident 1. The Psychological Consultation indicated Resident 1 was seen by the Psychologist through a telehealth (the use of communications technologies to provide health care at a distance) session using a non-public remote communication product (use of phone or computer). The Psychological Consultation indicated the Psychologist was in his office while Resident 1 was in the facility. The Psychological Consultation indicated Resident 1 had no psychotropic medication (relating to or denoting drugs that affect a person ' s mental state) and appeared to not be aware of what the Psychologist was referring to when the subject of unwanted contact by other resident was brought up. Resident 1 denied any issues or concerns with other residents. The Psychological Consultation indicated 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 F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide reasonable accommodations for residents needs and preferences for one of six sampled residents (Resident 2), when Resident 2 reques...
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Based on interview and record review, the facility failed to provide reasonable accommodations for residents needs and preferences for one of six sampled residents (Resident 2), when Resident 2 requested for a room change.
This deficient practice had the potential to negatively impact the psychosocial wellbeing of the resident.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 9/15/2020, with diagnoses that included type two diabetes mellitus (blood glucose, or blood sugar levels are too high), unspecified (unconfirmed) dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
A review of Resident 2 ' s History and Physical, dated 1/2/2024, indicated Resident 2 can make needs known but cannot make medical decisions.
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 3/22/2024, indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 2 needed supervision from staff for walking and transfers.
A review of Resident 2 ' s Change of Condition Evaluation (COC), dated 5/26/2024, indicated Resident 2 was found on top of Resident 1. The COC indicated on 5/26/2024 at 9 p.m., Licensed Vocational Nurse 1 (LVN 1) responded to sound of verbal altercation (loud argument) coming from Resident 1 and Resident 2 ' s room. The COC indicated LVN 1 saw Certified Nursing Assistant 2 (CNA 2) and CNA 3 removing Resident 2 on top of Resident 1. CNA 2 reported to LVN 1 that Resident 2 was on top groping (feel or fondle someone for sexual pleasure, especially against their will) and kissing Resident 1. The COC indicated Resident 1 stated Resident 2 was touching and kissing him non consensually (without permission). The COC indicated Medical Doctor (MD) was notified at 9 p.m. and Family Member 2 (FM 2) was notified at 10 p.m.
A review of Resident 2 ' s Progress Note dated 5/26/2024, indicated at 9 p.m. LVN 1 responded to sound of verbal altercation and saw CNA ' s removing Resident 1 on top of Resident 2. LVN 1 had Resident 2 removed from the room and placed on one-to-one staff monitoring (involves a nurse or carer providing support specifically to one individual).
A review of Resident 2 ' s Care Plan on risk for safety related to behavioral change dated 5/27/2024, indicated an intervention to provide one on one monitoring to ensure the safety of Resident 2 and other residents.
During a concurrent interview and record review on 5/30/2024 at 12:11 p.m., with the Medical Records Director (MRD), facility ' s census dated 5/26/2024 was reviewed. The census indicated male rooms available were rooms: B, C, D and E. The MRD stated four male rooms were available.
During an interview on 6/6/2024 at 11:30 a.m., Registered Nurse 2 (RN 2) stated on 5/27/2024 when he came in at 7 a.m., Resident 2 was in Station E with RN 1. RN 2 stated Resident 2 was still assigned in the same room with Resident 1. RN 2 stated when he came in there was no room change made. RN 2 stated their protocol when there is resident to resident altercation (quarrel) is to separate residents and make room changes. RN 2 stated RN 1 should have made the room change.
During an interview on 6/6/2024 at 6:40 p.m., CNA 10 stated he was assigned to Resident 2 on 5/26/2024 from 11 p.m., CNA 10 stated he tried to put Resident 2 back on the bed at 12 midnight in the same room with Resident 1 but Resident 2 refused and requested a room change. CNA 10 stated it was too late for room changes. CNA 10 stated he informed LVN 2 of Resident 2 ' s request for room changes and LVN 2 informed him that there were no rooms available.
During an interview on 6/6/2024 at 6:43 p.m., LVN 2 stated Resident 2 stayed the night in the hallway. LVN 2 stated they did not move him out of Resident 1 ' s room because all male rooms were occupied. LVN 2 stated Room B had one available male bed, but she does not want to have Resident 2 inside the room with residents who cannot talk and call for assistance.
During a concurrent interview and record review on 6/7/2024 at 12:37 p.m. with the Director of Nursing (DON), facility ' s policy and procedure (PnP) titled, Room Change Room Assignment undated and reviewed by Patient Care Policy Committee on 4/2024 was reviewed. The PnP indicated, Changes in room or roommate assignment are made when the facility deems it necessary or when the resident request the change. Resident preferences are taken into account when such changes are considered. The DON stated after the incident with Resident 1, the facility tried to transfer Resident 2 out to General Acute Care Hospital 1 (GACH 1). The DON stated CNA 10 ' s response that no other rooms available was not the right response. The DON stated their PnP indicated resident may request a room change.
During an interview on 6/7/2024 at 1:31 p.m., the DON stated if Resident 2 had one to one assigned CNA, he could be transferred to another room with another 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 2) ' s Family Member 2 (FM 2) was notified of Resident 2 ' s change in condition when on 5/11...
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Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 2) ' s Family Member 2 (FM 2) was notified of Resident 2 ' s change in condition when on 5/11/2024, Resident 2 ' s lips, left eye and left cheek were swollen.
This deficient practice had the potential to result in delayed provision of necessary care and services.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 9/15/2020, with diagnoses that included type two diabetes mellitus (blood glucose, or blood sugar levels are too high), unspecified (unconfirmed) dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
A review of Resident 2 ' s History and Physical dated 1/2/2024, indicated Resident 2 can make needs known but cannot make medical decisions.
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 3/22/2024, indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 2 needed supervision from staff for walking and transfers.
A review of Resident 2 ' s Change in Condition (COC) dated 5/11/2024, indicated Licensed Vocational Nurse 4 (LVN 4) documented that Resident 2 ' s lips, left eye and left cheek were swollen. The COC indicated Resident 2 was not sure of what happened. The COC indicated the Medical Doctor (MD) was notified at 7:50 a.m., that Resident 2 was chewing on tobacco. The COC indicated FM 2 was not notified.
A review of Resident 2 ' s Progress Note dated 5/11/2024, indicated FM 2 was not notified of Resident 2 ' s change in condition.
During a concurrent interview and record review on 6/5/2024 at 8:29 a.m., with LVN 4, Resident 2 ' s COC dated 5/11/2024 was reviewed. The COC indicated FM 2 was not notified as resident was self-responsible. LVN 4 stated she was aware that Resident 2 had history of dementia and schizophrenia. LVN 4 stated she did call FM 2 but forgot to document that she called.
During an interview on 6/5/2024 at 8:51 a.m., the Director of Nursing (DON) stated LVN 4 should have called and documented that she called FM 2.
During a concurrent interview and record review on 6/7/2024 at 12:37 p.m., with the DON, facility ' s policy and procedure (PnP) titled, Change in a Resident ' s Condition or Status dated 5/2017 and reviewed on 4/2024 indicated, Unless otherwise instructed by the resident, a nurse will notify the resident representative when: b. there is a significant change in the resident ' s physical, mental, or psychosocial status. The DON stated they do not have documented evidence that FM 2 was notified.
A review of facility ' s PnP titled, Charting and Documentation undated and reviewed on 4/2024, indicated, Documentation of procedures and treatments will include care-specific details including: f. notification of family, physician, or other staff, if indicated.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to thoroughly i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to thoroughly investigate a resident to resident sexual abuse for two of six sampled residents (Resident 1 and Resident 2) by:
1. Failing to interview and clarify written statements of witnesses (Certified Nursing Assistant 2 [CNA 2] and CNA 3).
2. Failing to interview and document Resident 1 and Resident 2 ' s roommates (Resident 6 and Resident 7).
3. Failing to verify one to one staff monitoring (involves a nurse or carer providing support specifically to one individual) were provided to Resident 2 as indicated in Resident 2 ' s Progress Note, Care Plan and Administrator ' s (ADM) facility Investigation Report.
4. Failing to document incident date correctly in the facility ' s Investigation Report.
This deficient practices had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/12/2018 with diagnoses that included end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest; symptoms may include shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]), hemiplegia (the loss of the ability to move on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant (preference to use one side of the body over the other) side and anxiety disorder (persistent and excessive worry that interferes with daily activities).
A review of Resident 1 ' s History and Physical (H&P) dated 1/2/2024 indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 4/18/2024, indicated Resident 1 needed maximum assists from staff for lower body dressing (ability to dress and undress below the waist), bed mobility from sitting to standing and walking. The MDS indicated Resident 1 was occasionally incontinent (unable to control) of bowel and bladder functions.
A review of Resident 1 ' s Psychologist Note dated 5/13/2024 indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding).
A review of Resident 1 ' s Change in Condition Evaluation (COC) dated 5/27/2024 indicated on 5/26/2024, Resident 2 was found on top of Resident 1. The COC indicated Resident 1 denied pain and had no bruising. The COC indicated the Medical Doctor (MD) was notified on 5/26/2024 at 9 p.m. and ordered to assess Resident 1 emotionally and psychologically. The COC indicated the paramedics arrived at 9:45 p.m., but Resident 1 refused to be transferred to emergency room.
A review of Resident 1 ' s Progress Note dated 5/27/2024 timed at 00:14 a.m., indicated Licensed Vocational Nurse 1 (LVN 1) responded to a sound of verbal altercation (loud argument) on 5/26/2024 at 9 p.m., from Resident 1 and Resident 2 ' s room. The Progress Note indicated LVN 1 saw CNA 2 removing Resident 2 on top of Resident 1 while Resident 1 was in his bed. The Progress Note indicated CNA 2 and CNA 3 reported that Resident 2 was groping (feel or fondle someone for sexual pleasure, especially against their will) and kissing Resident 1. The Progress Note also indicated that Resident 1 reported that Resident 2 was on top of Resident 1 touching him and kissing him non-consensually (without permission). The Progress notes indicated LVN 1 had Resident 2 removed from the room and placed on one-to-one staff monitoring. The Progress Note indicated LVN 1 observed Resident 1 shaking.
A review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 9/15/2020 with diagnoses that included type two diabetes mellitus (blood glucose, or blood sugar levels are too high), unspecified (unconfirmed) dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
A review of Resident 2 ' s H&P dated 1/2/2024 indicated Resident 2 can make needs known but cannot make medical decisions.
A review of Resident 2 ' s MDS dated [DATE] indicated Resident 2 ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 2 needed supervision from staff for walking and transfers.
A review of Resident 2 ' s Care Plan on risk for safety related to behavioral change dated 5/27/2024 indicated an intervention to provide one on one monitoring to ensure the safety of the Resident 2 and other residents.
A review of Resident 2 ' s Progress Note dated 5/26/2024 indicated at 9 p.m. LVN 1 responded to sound of verbal altercation and saw CNA ' s removing Resident 1 on top of Resident 2. LVN 1 had Resident 2 removed from the room and placed on one-to-one monitoring. The Progress Note indicated Resident 1 was on continued one to one monitoring by CNA and endorsed to the next shift to coordinate and maintain one to one observation by CNA.
A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 12/21/2022 with diagnoses that included nontraumatic chronic subdural hemorrhage (an old clot of blood on the surface of the brain beneath its outer covering), essential hypertension ( when you have abnormally high blood pressure that's not the result of a medical condition) and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain, depriving them of oxygen).
A review of Resident 6 ' s MDS dated [DATE] indicated Resident 6 ' s cognitive skills for daily decisions were severely impaired.
A review of Resident 7 ' s admission Record indicated the facility admitted the resident on 11/23/2022 with diagnoses that included hemiplegia and hemiparesis, type two diabetes mellitus and essential hypertension.
A review of Resident 7 ' s MDS dated [DATE] indicated Resident 7 ' s cognitive skills for daily decisions were severely impaired.
During an interview on 5/28/2024 at 3:42 p.m., with Registered Nurse 1 (RN 1), RN 1 stated on 5/26/2024 between 9 p.m., to 10 p.m., she was in Station C when she was paged to Resident 1 and Resident 2 ' s room. RN 1 stated she saw CNA 2, CNA 3, LVN 1 inside Resident 1 ' s room. RN 1 stated she saw Resident 1 in his bed and Resident 2 outside the room with LVN 5. RN 1 stated LVN 1 reported that CNA 2 and CNA 3 heard Resident 1 screaming and found Resident 2 on top of Resident 1. RN 1 stated Resident 2 stayed up all night, did not want to go to his room and was placed on one-to-one monitoring. RN 1 stated LVN 5 monitored Resident 2 on 5/26/2024 from 10 p.m., until 11 p.m., and CNA 10 monitored Resident 2 on 5/26/2024 from 11 p.m. until 7 a.m. on 5/27/2024.
During a concurrent interview and record review on 5/30/2024at 11:55 a.m., with the ADM, facility ' s policy and procedure (PP) titled, Abuse and Neglect-Clinical Protocol, last reviewed on 4/2024 was reviewed. The PP indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimation or punishment with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual abuse is defined as nonconsensual sexual contact of any type with a resident. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm The ADM stated on 5/26/2024 at 9 p.m., CNA 2 and CNA 3 heard a loud commotion and found Resident 2 on top of Resident 1 attempting to kiss and grope Resident 1. Resident 2 was removed from the room and placed on one-on-one staff monitoring. The ADM stated the abuse definition indicated for abuse to happen it should be willful and Resident 2 does not have capacity to make decisions and was not in his right mind. The ADM stated there was no foul play and the incident was not an abuse.
During an interview on 5/31/2024 at 12:45 p.m., the ADM stated he did not talk to CNA 2 and CNA 3. The ADM stated RN 1 got the written statement from the witnesses. The ADM stated their policy indicated investigation can be delegated to other individuals.
During an interview on 5/31/2024 at 1:35 p.m., with RN 1, RN 1 stated she asked CNA 2, CNA 3 and LVN 1 to write their statements. RN 1 stated CNA 2 wrote her statement in Spanish, but RN 1 stated she does not understand Spanish. RN 1 stated she asked Receptionist 1 (RC 1) to translate what CNA 2 wrote.
During a concurrent interview and record review on 5/31/2024 at 1:46 p.m., with the Director of Nursing (DON), facility ' s PnP titled, Abuse Investigation and Reporting dated 7/2017 and reviewed on 4/2024 indicated Role of the investigator:
1. the individual conducting the investigation will, as a minimum:
c. interview the person(s) reporting the incident.
d. Interview any witnesses to the incident.
g. interview staff members (on all shift) who have had contact with the resident during the period of the alleged incident.
h. interview the resident ' s roommate, family members or visitors.
The DON stated she was part of the investigation. The DON stated she interviewed RN 1, LVN 1, and CNA 1. The DON stated she was not able to talk to CNA 2 and CNA 3. The DON stated Resident 1 and Resident 2 ' s roommates (Resident 6 and Resident 7) were both non interviewable. The DON stated Resident 7 had a recent change in condition and just returned from the hospital while Resident 6 was confused. The DON stated there were no documentation that Resident 6 and Resident 7 were attempted to be interviewed. The DON stated, she and the ADM reviewed the witness written statement.
During a concurrent interview and record review on 5/31/2024 at 1:55 p.m., with the ADM, CNA 2 ' s written Investigation Statement were reviewed. The Investigation Statement dated 5/26/2024 timed at 8:45 p.m., was written in Spanish. The ADM stated he understands and speaks Spanish but provided an online translated copy in English that indicated, When CNA 2 was doing her rounds, CNA 2 heard someone scream for help. CNA 2 went to check the room and when CNA 2 got to Resident 1 and Resident 2 ' s room, CNA 2, and CNA 3, saw Resident 1 in bed with his feet down. Resident 1 lying down with his pants down and Resident 2 was trying to pull down Resident 1 ' s pants next to his bed. Resident 2 was on top of Resident 1. CNA 2 separated the residents and took Resident 2 out of the room. LVN 1 arrived, and Resident 2 was out of the room. The ADM stated he did not speak to CNA 2 about her written statement.
During a concurrent interview and record review on 5/31/2024 at 2:01 p.m., with the ADM, the Facility ' s Investigation on Resident 1 and Resident 2 ' s incident dated 5/30/2024 was reviewed. The Facility ' s Investigation indicated Incident happened on 5/27/2024 at approximately 9 p.m. The Facility ' s Investigation indicated on 5/26/2024 at 10 p.m., police officers arrived in the facility. In conclusion the facility cannot confirm Resident 2 ' s capacity to act deliberately with any realistic intentions and the facility cannot confirm Resident 2 ' s willfulness. The ADM stated he did not talk to Resident 1, and he based the conclusion of the investigation from LVN 1 who stated nothing happened. The ADM stated Resident 1 and Resident 2 were together in bed but Resident 1 reported nothing happen.
During a concurrent interview and record review on 5/31/2024 at 2:09 p.m., with the ADM, CNA 3 ' s written Investigation Statement was reviewed. The Investigation Statement dated 5/26/2024 timed at 8:45 p.m., indicated, CNA 2 and CNA 3 were walking in the hallway when they heard somebody screamed. CNA 3 wrote that they found him on the floor lying on another resident. The Investigation Statement indicated Resident 2 was trying to pull Resident 1 ' s pants. The ADM stated he does not know if CNA 3 ' s written statement was accurate because the Adm did not talk to CNA 3. The ADM stated people should not make assumption on what they were seeing. The ADM stated Resident 1 and Resident 2 were together in bed but Resident 1 said nothing happened. The ADM stated he was the Abuse Coordinator and he delegated the task of interviewing the witness and gathering the witness statement to RN 1.
A review of LVN 1 ' s written Investigation Statement dated 5/26/2024 timed at 9 p.m., indicated, LVN 1 was passing medication in Station A when she heard a commotion. LVN 1 ran and saw CNA 2 and CNA 3 separating Resident 1 and Resident 2. The Investigation Statement indicated CNAs reported that they found Resident 2 on top, kissing and groping (to touch someone's body to get sexual pleasure) Resident 1. The Investigation Statement indicated Resident 1 appeared in shock. The Investigation Statement indicated LVN 1 had Resident 2 removed from the room and placed on one-to-one staff monitoring.
During an interview on 6/3/2024 at 8:11 p.m., LVN 1 stated she asked CNA 2 and CNA 3 write their statements but admitted she did not read it and informed CNA 2 and CNA 3 to give their statements to RN 1. LVN 1 stated DON and ADM does the investigation and interviews. LVN 1 stated the only interview she had with the CNAs was the time when the incident happened and LVN 1 stated she did not verify what CNA 2 and CNA 3 wrote down.
During an interview on 6/3/2024 at 8:49 p.m., RN 1 stated she received CNA 2, CNA 3 and LVN 1 ' s written witness statement but she did not clarify what they wrote and just transcribed it to the risk management form. RN 1 stated she notice that the witness statement had a slight difference because CNA 3 wrote on the floor. RN 1 stated she should have clarified the witnesses' statements.
During a concurrent interview and record review on 6/7/2024 at 12:37 p.m., with the DON, facility ' s PP titled, Identifying Sexual Abuse and Capacity to Consent undated and reviewed on 4/2024, indicated, Sexual abuse includes but is not limited to a. unwanted intimate touching of any kind especially of breast and perineal area .Generally, Sexual contact is nonconsensual if the resident either a. appears to want the contact to occur but lacks the cognitive ability to consent or b. does not want the contact to occur. For any alleged violation or suspicion of sexual abuse, protective measures and an investigation will begin immediately. These include c. conducting a thorough investigation of the allegation, including the resident ' s capacity to consent and d. thoroughly documenting and reporting the result of the investigation of the allegation. The DON stated it is their policy to conduct a thorough investigation. The DON stated LVN 1, CNA 2 and CNA 3 were interviewed by RN 1. The DON stated she read the written statements and asked LVN 1 why CNA 3 wrote a statement about a resident lying on the floor. The DON stated she did not speak to CNA 2 and CNA 3 as they were off on the day she conducted the interviews, and she had other things to do. The DON stated, the ADM who is the abuse coordinator, is the one that oversaw the investigation.
During an interview on 6/7/2024 at 1:07 p.m., the ADM stated it is their abuse policy to conduct a thorough investigation. The ADM stated it is their policy to interview witnesses and the residents involved. The ADM stated interview could be a statement, but it should be documented on what was asked and what was the response.
During a concurrent interview and record review on 6/7/2024 at 1:31 p.m., with the DON, Resident 2 ' s Care Plan on at risk for safety related to behavioral change dated 5/27/2024 indicated an intervention for one-to-one monitoring to ensure the safety of the resident and the other residents. The DON stated one-on-one staff monitoring means on staff is assigned to monitor one reisdent. The DON admitted the care plan was not followed because CNA 10 was assigned on 5/26/2024 from 11 p.m., to 7 a.m., to Resident 1, Resident 2, Resident 6, and Resident 7 instead of being assigned to Resident 2 only. The DON stated the sexual incident happened as it was witnessed by CNA 2 and CNA 3.
A review of facility ' s policy and procedure, titled, Abuse Investigation and Reporting dated 7/2017 and reviewed on 4/2024 indicated, Role of Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown origin source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator.
A review of facility ' s policy and procedure titled, Abuse Prevention Program: dated 12/2016 and reviewed on 4/2024 indicated, Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for two of six samp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for two of six sampled residents (Resident 1 and Resident 2) by:
1. Failing to implement one on one staff monitoring (involves a nurse or carer providing support specifically to one individual) to Resident 2 as indicated in Resident 2 ' s care plan on at risk for safety dated 5/27/2024.
2. Failing to develop a care plan to address Resident 1 ' s refusal to walk with Restorative Nursing Assistant (RNA) on 5/29/2024.
These deficient practices had the potential for delayed provision of necessary care and services.
Findings:
a. A review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 9/15/2020, with diagnoses that included type two diabetes mellitus (blood glucose, or blood sugar levels are too high), unspecified (unconfirmed) dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
A review of Resident 2 ' s History and Physical (H&P) dated 1/2/2024 indicated Resident 2 can make needs known but cannot make medical decisions.
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 3/22/2024 indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 2 needed supervision from staff for walking and transfers.
A review of Resident 2 ' s Change in Condition (COC) Evaluation dated 5/26/2024 indicated Resident 2 was found on top of Resident 1. The COC indicated on 5/26/2024 at 9 p.m., Licensed Vocational Nurse 1 (LVN 1) responded to sound of verbal altercation (noisy argument) coming from Resident 1 and Resident 2 ' s room. The COC indicated LVN 1 saw Certified Nursing Assistant 2 (CNA 2) and CNA 3 removing Resident 2 on top of Resident 1. CNA 2 and CNA 3 reported to LVN 1 that Resident 2 was on top groping (feel or fondle someone for sexual pleasure, especially against their will) and kissing Resident 1. The COC indicated Resident 1 stated Resident 2 was touching and kissing him non consensually (without permission).
A review of Resident 2 ' s Care Plan on risk for safety related to behavioral change dated 5/27/2024 indicated an intervention to provide one-on-one monitoring to ensure the safety of Resident 2 and other residents.
During an interview on 5/28/2024 at 3:42 p.m., Registered Nurse 1 (RN 1) stated on 5/26/2024 from 10 p.m. to 11 p.m., LVN 5 was assigned to provide one-on-one monitoring for Resident 2, then from 11 p.m. to 7 a.m., CNA 10 was assigned provide one-on-one monitoring for Resident 2.
During an interview on 5/30/2024 at 11:55 a.m., the Administrator (ADM) stated on 5/26/2024 that after the incident between Resident 1 and Resident 2, Resident 2 was removed from the room and was placed on one-on-one staff monitoring.
During an interview on 6/6/2024 at 6:40 p.m., CNA 10 stated he was assigned to provide monitoring for Residents 1 and 2 and was also assigned to care for Residents 6 and 7. CNA 10 stated he was assigned to care for all four residents in Room A from 11 p.m. until 7 a.m.
During an interview on 6/6/2024 at 6:56 p.m., the Assistant Director of Nursing (ADON) stated one to one staff monitoring means one resident for one staff. The ADON stated Resident 2 ' s care plan for one-on-one staff monitoring was not followed.
During an interview on 6/6/2024 at 7:14 p.m., with the Director of Nursing (DON), the DON stated on 5/26/2024 when RN 1 notified her of the incident, the DON gave an instruction to RN 1 make sure Resident 2 will have one-on-one staff monitoring.
During a concurrent interview and record review on 6/7/2024 at 12:37 p.m., with the DON, the facility ' s policy and procedure (PnP) titled, Comprehensive Person-Centered Care Plans dated 12/2016 and reviewed on 4/2024 indicated Each resident ' s comprehensive person -centered care plan will be consistent with the resident ' s rights to participate in the development and implementation of his or her plan of care, including the right to: g. Receive the services and or items included in the plan of care. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain and maintain the residents highest practicable physical, mental, and psychosocial well-being. The DON stated their policy indicated residents will receive the services listed in the care plan. The DON stated staff should follow Resident 2 ' s care plan for one on one.
b. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/12/2018 with diagnoses that included end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest. Symptoms may include shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]), hemiplegia (the loss of the ability to move on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant (preference to use one side of the body over the other) side.
A review of Resident 1 ' s H&P dated 1/2/2024 indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1 ' s MDS dated [DATE], indicated Resident 1 ' s cognitive skills for daily decisions were severely impaired.
A review of Resident 1 ' s Physician ' s Order dated 3/27/2024 indicted an order for the RNA to complete right upper extremity (arm) passive range of motion (PROM- someone physically moves or stretches a part of your body, such as your arm) with Resident 1 daily five times a week or as tolerated, along with donning (put on) right resting hand splint (supports your hand and wrist in the best position while you are resting daily) five times a week for two to four hours or as tolerated.
During an interview on 5/29/2024 at 11:24 a.m., RNA 1 stated sometimes Resident 1 refuses to ambulate. RNA 1 stated when the resident refuses, she informs the nurses and documents that the resident refused.
A review of Resident 1 ' s Documentation Survey Report dated 5/2024 indicated Resident 1 had refused RNA three times on 5/29/2024.
During an interview on 6/6/2024 at 3:30 p.m., with the Medical Records Director (MRD), the MRD stated there was no care plan created for Resident 1 ' s refusal for RNA treatment.
During a concurrent interview and record review on 6/6/2024 at 3:44 p.m., with the Assistant Director of Nursing (ADON), Resident 1 ' s Care Plans were reviewed. The ADON stated there was no care plan created for the resident's refusal for RNA treatment.
During a concurrent interview and record review on 6/7/2024 at 12:37 p.m., with the Director of Nursing (DON), facility ' s policy and procedure (PnP) titled, Comprehensive Person-Centered Care Plans dated 12/2016 and viewed on 4/2024 indicated, The comprehensive, person-centered care plan will: c. Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her right, including the right to refuse treatment. The resident has the right to refuse to participate in the development of his or her care plan and medical and nursing treatments. Such refusal will be documented in the resident ' s clinical record in accordance with established policies. The DON stated staff should create a care plan on residents ' refusal of treatment.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to follow professional standards of practice for one of six sampled residents (Resident 1) when Licensed Vocational Nurse 1 (LVN 1) and Regis...
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Based on interview, and record review, the facility failed to follow professional standards of practice for one of six sampled residents (Resident 1) when Licensed Vocational Nurse 1 (LVN 1) and Registered Nurse 1 (RN 1) did not check Resident 1 ' s vital signs (measurements of the body's most basic functions that includes blood pressure [the force of your blood pushing against the walls of your arteries], heartrate, respiratory rate [the number of breaths a person takes per minute], oxygen saturation [amount of oxygen level of the blood], and temperature) when Resident 1 had a change in condition on 5/26/2024.
This deficient practice had the potential to place Resident 1 at risk for undetected elevated high blood pressure, heart rate, respiration and temperature which could negatively impact the resident's healh and safety.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/12/2018 with diagnoses that included end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest. Symptoms may include shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]), hemiplegia (the loss of the ability to move on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant (preference to use one side of the body over the other) side and essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition).
A review of Resident 1 ' s History and Physical (H&P) dated 1/2/2024 indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 4/18/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.
A review of Resident 1 ' s Change in Condition Evaluation (COC) dated 5/27/2024 indicated on 5/26/2024, Resident 2 was found on top of Resident 1 at 8:45 p.m. The COC indicated Resident 1 denied pain and had no bruising. The COC indicated the Medical Doctor (MD) was notified on 5/26/2024 at 9 p.m. and ordered to assess Resident 1 emotionally and psychologically. The COC indicated the paramedics arrived at 9:45 p.m., but Resident 1 refused to be transferred to emergency room. The COC indicated the most recent vital signs taken was on 5/26/2024 at 5:42 p.m.
A review of Resident 1 ' s Progress Note dated 5/27/2024 timed at 12:14 a.m., indicated on 5/26/2024 at 9 p.m., Licensed Vocational Nurse 1 (LVN 1) responded to a sound of verbal altercation (loud argument). LVN 1 saw Certified Nursing Assistant 2 (CNA 2) and CNA 3 removing Resident 2 on top of Resident 1 who was laying in his bed. LVN 1 observed Resident 1 shaking. The Progress Note indicated no vital signs was documented.
A review of Resident 1 ' s Weights and Vitals Summary indicated from 5/26/2024 at 8:45 p.m. to 5/27/2024 at 3 a.m., Resident 1 had no documented vital signs.
During a concurrent interview and record review on 6/6/2024 at 5:40 p.m., with the Director of Nursing (DON), Resident 1 ' s COC and Progress Note dated 5//26/2024 were reviewed. The DON stated Resident 1 ' s COC and Progress Note had no vital signs during the incident. The DON stated nurses should check Residents 1 ' s vital signs as part of the COC.
During a concurrent interview and record review on 6/7/2024 at 12:37 p.m., with the DON, facility ' s policy, and procedure (PnP), titled Resident Examination and Assessment undated and reviewed on 4/2024 indicated The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Physical Exam: 1. Vital signs: a. blood pressure, b. pulse, c. respirations, d. temperature. The following information should be recorded in the resident medical record: 3. All assessment data obtained during the procedure. Notify the physician of any abnormalities such as, but not limited to: a. abnormal vital signs. The DON stated taking vital signs with any COC was indicated in the Resident Examination and Assessment PnP.
A review of facility ' s Pnp titled, Change in a Resident ' s Condition or Status dated 5/2017 and reviewed on 4/2024 indicated, Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact Situation Background Assessment and Recommendation (SBAR-a technique that provides a framework for communication between members of the health care team about a resident ' s condition) Communication Form.
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 F0712
(Tag F0712)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the face-to-face visit was made by a physician or alternate ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the face-to-face visit was made by a physician or alternate visits by a nurse practitioner was conducted timely according to the facility ' s policy and procedures on Physician Visits for four of 17 sampled residents (Resident 14, Resident 15, Resident 16, and Resident 17).
This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment, and services.
Findings:
A review of Resident 14 ' s admission Record indicated the facility admitted the resident on 9/2/2023 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), angina pectoris (chest pain or discomfort that kept coming back), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).
A review of Resident 14 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/8/2024, indicated the resident ' s cognitive (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions) skills were severely impaired.
A review of Resident 14 ' s History and Physical (H and P), dated 1/2/2024, indicated NP 1 visited and assessed the resident. The H and P did not indicate that Attending Physician 1 (MD 1) visited Resident 14.
A review of Resident 14 ' s Attending Progress Note, dated 3/7/2024, 4/18/2024, and 5/9/2024, indicated that NP 2 visited and assessed the resident. The note did not indicate that MD 1 visited Resident 14.
A review of Resident 15 ' s admission Record indicated the facility admitted the resident on 8/10/2022 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), and dysphagia (a condition that makes it difficult to swallow).
A review of Resident 15 ' s MDS, dated [DATE], indicated the resident ' s cognitive skills were intact.
A review of Resident 15 ' s Attending Progress Note, dated 3/7/2024, 4/18/2024, and 5/9/2024, indicated that NP 2 visited and assessed the resident. The note did not indicate that MD 1 visited Resident 15.
A review of Resident 16 ' s admission Record indicated the facility admitted the resident on 4/3/2024 with diagnoses including asthma (a disease that affects the lungs), essential hypertension, and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities).
A review of Resident 16 ' s MDS, dated [DATE], indicated the resident ' s cognitive skills were intact.
A review of Resident 16 ' s Attending Progress Note, dated 3/7/2024, 4/18/2024, and 5/9/2024, indicated that NP 2 visited and assessed the resident. The note did not indicate that MD 1 visited Resident 16.
A review of Resident 17 ' s admission Record indicated the facility admitted the resident on 12/27/2023 with diagnoses including type 2 diabetes mellitus, essential hypertension, and depression.
A review of Resident 17 ' s MDS, dated [DATE], indicated the resident ' s cognitive skills were intact.
A review of Resident 17 ' s H and P, dated 12/28/2023 and 1/6/2024, indicated NP 1 visited and assessed the resident. The H and P did not indicate that MD 1 visited Resident 17.
A review of Resident 17 ' s Attending Progress Note, dated 3/12/2024, 4/23/2024, and 5/14/2024, indicated that NP 2 visited and assessed the resident. The note did not indicate that MD 1 visited Resident 17.
On 6/6/2024 at 4:57 p.m., during a concurrent interview and record review, Resident 14, Resident 15, Resident 16, and Resident 17 ' s medical record were reviewed with the Assistant Director of Nursing (ADON). The ADON stated that there was no documented evidence that Resident 14, Resident 15, Resident 16, and Resident 17 ' s attending physician visited the resident. The ADON confirmed that the documented visits were made by NP 1 and NP 2. The ADON stated that physicians should visit the residents and write their notes. The ADON stated that the facility failed to ensure that attending physicians visited the residents according to the facility ' s policy and procedures.
On 6/6/2024 at 5:40 p.m., during an interview, the Director of Nursing (DON) stated that she had a phone meeting with MD 1 on 6/6/2024 after the deficient practice was identified. The DON stated that MD 1 informed her that moving forward MD 1 will make and sign the progress notes during MD 1 ' s visit to the residents.
A review of the facility ' s policy and procedure titled, Physician Visits, reviewed on 4/2024, indicated the attending physician must visit his/her patients at least once every 30 days for the first 90 days following the resident ' s admission and then at least every 60 days thereafter. The policy indicated that after the first 90 days, if the attending physician determines that a resident need not be seen by him every 30 days, an alternate schedule of visits may be established, but not to exceed every 60 days. A physician assistant or NP may make alternate visits after the initial 90 days following admission.
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 eight of eight sampled facility staff (Director of Staff Dev...
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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 eight of eight sampled facility staff (Director of Staff Development [DSD], Social Services Director [SSD], Licensed Vocational Nurse 7 [LVN 7], LVN 11, LVN 12, Certified Nursing Assistant 2 [CNA 2], CNA 16, and CNA 17) were competent to provide appropriate services to assure residents were free from abuse by failing to:
1. Provide in-service education that included sexual abuse prevention for the facility ' s resident population.
2. Ensure the in-services (staff training) lesson plan content was accurate.
3. Ensure annual competencies (measurable pattern of knowledge, skills, abilities, behaviors in order to perform occupational functions successfully) were completed for the SSD, LVN 11, CNA 16, and CNA 17.
As a result, Resident 1 was subjected to sexual abuse from Resident 2. These deficient practices had placed other residents at risk for sexual abuse.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/12/2018 with diagnoses that included end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest with symptoms including shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]), hemiplegia (the loss of the ability to move on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant (preference to use one side of the body over the other) side, and anxiety disorder (persistent and excessive worry that interferes with daily activities).
A review of Resident 1 ' s History and Physical (H&P) dated 1/2/2024 indicated the resident had the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 4/18/2024, indicated Resident 1 needed maximum assists from staff for lower body dressing (ability to dress and undress below the waist), bed mobility from sitting to standing and walking. The MDS indicated Resident 1 was occasionally incontinent (unable to control) of bowel and bladder functions.
A review of Resident 1 ' s Change in Condition Evaluation (COC), dated 5/27/2024, indicated that on 5/26/2024, Resident 2 was found on top of Resident 1. The COC indicated Resident 1 denied pain and had no bruising. The COC indicated the Attending Physician (AP) was notified on 5/26/2024 at 9 p.m. and ordered to assess Resident 1 emotionally and psychologically. The COC indicated the paramedics arrived at 9:45 p.m., but Resident 1 refused to be transferred to the emergency room.
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/15/2020, with diagnoses that included type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar [glucose]), unspecified (unconfirmed) dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
A review of Resident 2 ' s MDS dated [DATE] indicated the resident ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 2 needed supervision from staff for walking and transfers.
A review of the DSD ' s Job Description, dated 9/2020, indicated the duties and responsibilities of the DSD included to assess learning needs of personnel to meet the needs of the resident, organization, and employee. The job description indicated the DSD conducts research to ensure lesson plan content was accurate and up to date.
On 6/5/2024 at 1:25 p.m., during a concurrent interview and record review, the Abuse Prevention, Recognizing, and Reporting in-service lesson plan, dated 5/28/2024, was reviewed with the DSD. The lesson plan indicated the objectives which included to recognize evidence-based interventions for adolescent problematic sexual behaviors and to recall strategies to support caregivers in addressing adolescent sexual behaviors. The Content section of the lesson plan indicated adolescent behaviors and support of caregivers of adolescents. The DSD defined an adolescent as the age group after childhood and stated that an adolescent was an adult. The DSD stated the residents in the facility were a mix of adults and seniors. The DSD stated there were no residents in the facility within the adolescent age group. The DSD was not able to state all the types of abuse.
On 6/5/2024 at 1:51 p.m., during an interview, LVN 11 stated that the facility provided abuse prevention and reporting in-services but not specific to sexual abuse. LVN 11 stated that the in-service on abuse did not include the signs and symptoms to look for on residents at risk for sexual abuse.
On 6/5/2024 at 2 p.m., during an interview, LVN 12 stated that the facility provided in-services on abuse after the incident. LVN 12 stated that he had not attended the in-services because he was busy at the nurse station.
On 6/5/2024 at 2:26 p.m., during a concurrent interview and record review, LVN 7 stated the facility provided abuse prevention and reporting in-services but were not specific to sexual abuse. A review of the facility provided abuse in-services sign in sheets indicated LVN 7 ' s name and signature were not on the sign in sheet. LVN 7 stated she was not informed that there was an ongoing in-service and stated if she knew she would have attended.
On 6/6/2024 at 2:14 p.m., during an interview, CNA 2 stated the facility provided in-services on abuse prevention and reporting but was not specific on sexual abuse. CNA 2 stated the in-service mentioned the types of abuse, who to report the abuse, and to report within two hours but not the signs to identify sexual abuse.
On 6/6/2024 at 6:39 p.m., during a concurrent interview and record review, the facility ' s employee files were reviewed with the Director of Nursing (DON) and the Assistant DON (ADON) and indicated that the SSD, LVN 11, CNA 16, and CNA 17 ' s annual competencies were not in the employee ' s file.
On 6/6/2024 at 7:10 p.m., during an interview, the ADON stated that annual competencies of the facility ' s nursing staff should be completed to ensure they were competent to provide nursing care to the residents.
On 6/7/2024 at 12:44 p.m., during a concurrent interview and record review, the facility ' s employee files were reviewed with the DSD. The DSD stated that should be completed annually to ensure the nursing staff provide competent nursing care to the residents. The DSD stated that the facility failed to ensure that all facility employees had their skills competencies completed on time.
A review of the facility ' s policy and procedure titled, Competency of Nursing Staff, date 4/2024, indicated that licensed nurses and nursing assistants employed by the facility will participate in a facility-specific, competency-based staff development and training program and demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents. The policy indicated that competency in skills and techniques necessary to care for residents ' needs included but not limited to competencies in areas such as .a. preventing abuse, neglect, and exploitation of resident property.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3a. A review of Resident 14 ' s admission Record indicated the facility admitted the resident on 9/2/2023 with diagnoses includi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3a. A review of Resident 14 ' s admission Record indicated the facility admitted the resident on 9/2/2023 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), angina pectoris (chest pain or discomfort that kept coming back), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).
A review of Resident 14 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/8/2024, indicated the resident ' s cognitive (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions) skills were severely impaired.
A review of Resident 14 ' s Physician Order for metoprolol tartrate (a medication that slows down the heart rate) 50 milligrams (mg – unit of measurement), dated 5/14/2024, did not indicate the time the physician order was written and the time the licensed nurse noted the physician order. The transcribed physician ' s order in the EHR indicated the communication method (the method the order was received) for the written physician order was by telephone.
3b. A review of Resident 15 ' s admission Record indicated the facility admitted the resident on 8/10/2022 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), and dysphagia (a condition that makes it difficult to swallow).
A review of Resident 15 ' s MDS, dated [DATE], indicated the resident ' s cognitive skills were intact.
A review of Resident 15 ' s Physician Order for ultrasound (a procedure that uses high-energy sound waves to look at tissues and organs inside the body) of the gallbladder (a small pear-shaped organ that stores and releases bile), dated 4/18/2024, did not indicate the time the physician order was written and the time the licensed nurse noted the physician order.
A review of Resident 15 ' s Physician Order for nephrology (a specialized branch of medicine focusing on the diagnosis and treatment of kidney disease) consult, dated 4/19/2024, did not indicate the time the physician order was written and the time the licensed nurse noted the physician order.
3c. A review of Resident 16 ' s admission Record indicated the facility admitted the resident on 4/3/2024 with diagnoses including asthma (a disease that affects the lungs), essential hypertension, and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities).
A review of Resident 16 ' s MDS, dated [DATE], indicated the resident ' s cognitive skills were intact.
A review of Resident 16 ' s Physician Order for guanfacine hydrochloride (a medication used to treat high blood pressure) 2 mg, dated 4/30/2024, did not indicate the time the physician order was written and the licensed nurse ' s signature, date, and time the physician order was noted. The transcribed physician ' s order in the EHR indicated the communication method for the written order was by telephone.
3d. A review of Resident 17 ' s admission Record indicated the facility admitted the resident on 12/27/2023 with diagnoses including type 2 diabetes mellitus, essential hypertension, and depression.
A review of Resident 17 ' s MDS, dated [DATE], indicated the resident ' s cognitive skills were intact.
On 6/5/2024 at 3:38 p.m., during a concurrent interview and record review, Resident 17 ' s Physician Orders were reviewed with Licensed Vocational Nurse 3 (LVN 3). LVN 3 stated that Resident 17 ' s Physician Order for Prednisone (a steroid medication) 10 mg, dated 5/14/2024, did not indicate the time the physician order was written and the time the licensed nurse noted the physician order. The transcribed physician ' s order in the EHR indicated the communication method for the written order was by telephone. LVN 3 stated that physician orders should be dated and timed. LVN 3 stated the method used to receive physician orders should be transcribed in the EHR accurately.
On 6/6/2024 at 3:44 p.m., during a concurrent interview and record review, Resident 14, Resident 15, Resident 16, and Resident 17 ' s clinical records were reviewed with the Director of Nursing (DON). The DON stated that physician orders should be timed and dated. The DON stated that licensed nurses should indicate the date and time the written orders were noted. The DON stated that licensed nurses should transcribe the physician orders to the EHR accurately.
A review of the facility ' s policy and procedure titled, Medication and Treatment Orders, reviewed on 4/2024, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing.
A review of the facility ' s policy and procedure titled, Telephone Verbal, Written, reviewed 4/2024, indicated written orders must be reviewed and readback by the person receiving the order from the physician and transcribed in the EHR.
A review of the facility ' s policy and procedure titled, Charting and Documentation, reviewed 4/2024, indicated that documentation in the medical record will be objective, complete, and accurate.
Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for five out of 17 sampled residents (Residents 2, 14, 15, 16, and 17) by:
1. Failing to accurately document supervision provided to Resident 2 on 5/26/2024 from 11 p.m. to 5/27/2024 7 a.m.
2. Failing to accurately document Resident 2 ' s blood pressure on 5/26/2024 at 9 a.m.
3. Failing to ensure the physician orders indicated the time the orders were written for Residents 14, 15, 16, and 17.
4. Failing to ensure the physician orders were accurately transcribed in the residents ' electronic health records (EHR) for Residents 14, 15, 16, and 17.
These deficient practices had the potential to result in inaccurate information in the residents ' clinical records and placed the residents at risk for not receiving the appropriate treatment and service due to inaccurate documentation.
Findings:
1. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/15/2020, with diagnoses that included type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar [glucose]), unspecified (unconfirmed) dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition).
A review of Resident 2 ' s History and Physical dated 1/2/2024, indicated the resident can make needs known but cannot make medical decisions.
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 3/22/2024, indicated the resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 2 needed supervision from staff for walking and transfers.
A review of Resident 2 ' s Change in Condition (COC) Evaluation dated 5/26/2024, indicated Resident 2 was found on top of Resident 1. The COC indicated on 5/26/2024 at 9 p.m., Licensed Vocational Nurse 1 (LVN 1) responded to sound of verbal altercation (noisy argument) coming from Resident 1 and Resident 2 ' s room. The COC indicated LVN 1 saw Certified Nursing Assistant 2 (CNA 2) and CNA 3 removing Resident 2 on top of Resident 1. CNA 2 and CNA 3 reported to LVN 1 that Resident 2 was on top groping (feel or fondle someone for sexual pleasure, especially against their will) and kissing Resident 1. The COC indicated Resident 1 stated Resident 2 was touching and kissing him non-consensually (without permission).
A review of Resident 2 ' s Progress Note dated 5/27/2024 timed at 7:51 a.m., indicated LVN 2 documented that Resident 2 was placed on one-on-one monitoring by CNA 10 and within observation by LVN 2 at nurses ' station the entire shift.
During an interview on 5/28/2024 at 3:42 p.m., Registered Nurse 1 (RN 1) stated on 5/26/2024 from 10 p.m., to 11 p.m., LVN 5 was assigned as one-on-one staff for Resident 2, then from 11 p.m. to 7 a.m., CNA 10 was assigned as one-to-one staff for Resident 2.
During an interview on 5/30/2024 at 11:55 a.m., the Administrator (ADM) stated on 5/26/2024 after the incident between Resident 1 and Resident 2, Resident 2 was removed from the room and was placed on one-on-one staff monitoring.
During an interview on 6/6/2024 at 6:40 p.m., CNA 10 stated he was assigned not only to Resident 2 but also to Resident 1, Resident 6, and Resident 7. CNA 10 stated he had four residents the night of 5/26/2024 to 5/27/2024 morning as he was assigned to all four residents in Room A.
During an interview on 6/6/2024 at 6:56 p.m., the Assistant Director of Nursing (ADON) stated one-on-one staff monitoring means one staff to one resident.
During an interview on 6/6/2024 at 7:14 p.m., the Director of Nursing (DON) stated on 5/26/2024 when RN 1 notified her of the incident, the DON gave instruction to RN 1 to make sure Resident 2 will have one-on-one staff monitoring.
A review of the facility ' s policy and procedure (PnP) titled, Charting Errors and or Omissions, dated 12/2006 and reviewed on 4/2024 indicated, Accurate medical records shall be maintained by this facility.
2. A review of Resident 2 ' s Physician Order dated 9/16/2020 indicated an order for benazepril hydrochloride (medication used to lower blood pressure and increases the supply of blood and oxygen to the heart) 20 milligrams (mg-unit of measurement) tablet. Give one tablet by mouth daily for hypertension and hold (do not administer) for systolic blood pressure (SBP- the pressure caused by your heart contracting and pushing out blood) less than 110.
During a concurrent interview and record review on 5/29/2024 at 10:06 a.m., with RN 2, Resident 2 ' s Progress Notes dated 5/2024 were reviewed. The Progress Notes on 5/26/2024 at 9 a.m., indicated Resident 2 ' s blood pressure was 19/59 and benazepril medication had a check mark. RN 2 stated check mark means medication was given and there were no Progress Note dated 5/25/2024 of the correct blood pressure. RN 2 stated it was a typographical error (a mistake made in the typing of printed or electronic material).
During an interview on 5/29/2024 at 12:27 p.m., the DON stated LVN 4 should recheck the blood pressure and hold the medication if that was the correct blood pressure of Resident 2.
During an interview on 6/5/2024 at 8:29 a.m., LVN 4 stated she had issues with the computer keyboard and thought she had made corrections that day. LVN 4 admitted missing Resident 2 ' s correct blood pressure documentation.
During a concurrent interview and record review on 6/7/2024 at 12:37 p.m., with the DON, the facility ' s policy and procedure (PnP) titled, Charting Errors and or Omissions, dated 12/2006 and reviewed on 4/2024 indicated, Accurate medical records shall be maintained by this facility. If an error was made while recording the data in the medical records, the line through the error with a single line and correct the error. The DON stated their PnP titled, Charting Errors and or Omission was applicable when they were still using paper documentation. The DON stated she will ask for the policy for late entry in computer documentation.
A review of facility ' s PnP titled, Charting and Documentation undated and reviewed on 4/2024 indicated, The following information is to be documented in the resident ' s medical record. B. Medications administered. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0838
(Tag F0838)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Facility Assessment (an examination of the resident popu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Facility Assessment (an examination of the resident population to determine the resources necessary to care for its residents competently during day-to-day operations and emergencies) was completed and reviewed annually.
This deficient practice had the potential to place residents at risk for functional, physical, mental, and psychosocial needs to not be met.
Findings:
On 6/6/2024 at 8:20 p.m., during a concurrent interview and record review, the Facility assessment dated [DATE], was reviewed with the Administrator (ADM). The ADM stated that the facility assessment was a snapshot of services the facility offered, the risk assessment of the facility, and quantified the number of residents the facility had and able to accommodate. The ADM stated the facility assessment did not indicate the complete process on care of residents with conditions not listed on their facility assessment, the complete list of health care professionals and staff members needed to provide resident care, and the staff competencies and trainings required for the facility ' s resident population. The ADM stated the facility assessment did not indicate all the equipment the facility had and able to provide for resident care and the location and content of the resident ' s medical records. The ADM stated the current facility assessment lacked detailed information, was not comprehensive but had no effect on resident care provided in the facility. The ADM stated that it was the administration ' s responsibility to ensure the facility assessment was thorough. The ADM stated that he will correct and make changes on the facility assessment.
A review of the facility ' s policy and procedure titled, Facility Assessment, reviewed on 4/2024, indicated a facility assessment was conducted annually to determine and update the facility ' s capacity to meet the needs of and competently care for the residents during day-to-day operations.
Apr 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered plan of care with measurable objectives and interventions for one of three sampled re...
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Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered plan of care with measurable objectives and interventions for one of three sampled residents (Resident 1). The facility failed to ensure Resident 1's care plan indicated the specific interventions addressing the resident's risk for falls.
As a result, on 4/10/2024 at 9:30 a.m., Resident 1 fell while Certified Nursing Assistant 1 (CNA 1) was transferring the resident from the bed to the wheelchair and sustaining a left elbow skin tear and a right knee abrasion.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 2/13/2024 with diagnoses including hemiplegia (paralysis that affects one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (result of disrupted blood flow to the brain because of problems with the blood vessels that supply it) affecting the left non-dominant side, type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), and essential hypertension.
A review of Resident 1's History and Physical, dated 2/16/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 1's Care Plan on falls, created on 2/16/2024, indicated that the resident was at risk for falls related to gait (the manner of walking or moving on foot) and balance problems. The care plan goal indicated that Resident 1 will be free from falls through the review date. The care plan interventions indicated to ensure that Resident 1 was wearing appropriate footwear when ambulating or mobilizing in the wheelchair. The required footwear was not described and specified in the care plan. The care plan interventions indicated that Resident 1 required a safe environment but there was no specific safety measures implemented.
A review of Resident 1's Care Plan on activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive), dated 2/16/2024, indicated that the resident had self-care performance deficit. The care plan interventions indicated that Resident 1 required assistance from the facility staff to move between surfaces and as necessary. The interventions did not indicate the specific level of assistance, the number of facility staff required to assist Resident 1, and the frequency the ADLs were to be performed.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/19/2024, indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The Functional Limitation in Range of Motion (refers to how far a person can move or stretch a part of the body) section indicated that Resident 1 had impairment on one side of the upper extremity (shoulder, elbow, wrist, and hand) and the lower extremity (hip, knee, ankle, and foot). Resident 1 was dependent on facility staff on rolling to left and right, sit to lying, and lying to sitting on the side of the bed. The MDS indicated that the sit to stand, chair or bed to chair transfer, toilet transfer, and walk 10 feet were not attempted with Resident 1's because of the resident's medical condition or safety concerns.
On 4/10/2024 at 10:43 a.m., during a concurrent observation and interview, observed Resident 1's left elbow with blood running down the resident's left arm. Resident 1 stated that the blood was from the fall that happened in the morning while the resident was assisted to the wheelchair.
On 4/10/2024 at 2:45 p.m., during a concurrent interview and record review, Resident 1's Care Plans were reviewed with the Director of Nursing (DON) and indicated that the resident was at risk for falls and had self-care deficits. The DON stated that care plans should be patient-centered, individualized, and specific. The DON stated that care plans that were not individualized and specific and had the potential to not address the Resident 1's needs.
A review of the facility's policy and procedures titled, Comprehensive Person-Centered Care Plans, dated 5/2023, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs were developed and implemented for each resident. The policy indicated that the comprehensive, person-centered care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was identified as high fall risk, was assessed after the resident had a witnessed fall from the wheelchair.
This deficient practice had the potential to result in inaccurate assessment that can lead to Resident 1 not receiving timely medical interventions.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 2/13/2024 with diagnoses including hemiplegia (paralysis that affects one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (a result of disrupted blood flow to the brain because of problems with the blood vessels that supply it) affecting the left non-dominant side, type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), and essential hypertension.
A review of Resident 1's History and Physical, dated 2/16/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 1's Care Plan on falls, created on 2/16/2024, indicated that the resident was at risk for falls related to gait (the manner of walking or moving on foot) and balance problems. The care plan goal indicated that Resident 1 will be free from falls through the review date. The care plan interventions indicated to ensure that Resident 1 was wearing appropriate footwear when ambulating or mobilizing in the wheelchair. The required footwear was not described and specified in the care plan. The care plan interventions indicated that Resident 1 required a safe environment but there were no specific safety measures implemented.
A review of Resident 1's Care Plan on activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive), dated 2/16/2024, indicated that the resident had self-care performance deficit. The care plan interventions indicated that Resident 1 required assistance from the facility staff to move between surfaces and as necessary. The interventions did not indicate the specific level of assistance, the number of facility staff required to assist Resident 1, and the frequency the ADLs were to be performed.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/19/2024, indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The Functional Limitation in Range of Motion (refers to how far a person can move or stretch a part of the body) section indicated that Resident 1 had impairment on one side of the upper extremity (shoulder, elbow, wrist, and hand) and the lower extremity (hip, knee, ankle, and foot). Resident 1 was dependent on facility staff on rolling to left and right, sit to lying, and lying to sitting on the side of the bed. The MDS indicated that the sit to stand, chair or bed to chair transfer, toilet transfer, and walk 10 feet were not attempted with Resident 1's because of the resident's medical condition or safety concerns.
A review of Resident 1's Fall Risk Evaluation, dated 3/25/2024, indicated the resident was a high fall risk. The Gait Evaluation section indicated that Resident 1 had balance problems while standing and walking, decreased muscular coordination, gait problems, and required the use of assistive devices.
On 4/10/2024 at 10:43 a.m., during a concurrent observation and interview, observed Resident 1's left elbow with blood running down the resident's left arm. Resident 1 stated that the blood was from the fall that happened in the morning at 9:30 a.m. while the resident was assisted to the wheelchair.
On 4/10/2024 at 10:56 a.m., during a concurrent observation and interview, observed Licensed Vocational Nurse 1 (LVN 1) asked Resident 1 if Registered Nurse 1 (RN 1) came to assess the resident after the fall. LVN 1 went out of Resident 1's room and later came back with RN 1. RN 1 stated that he did not assess Resident 1 after the fall. Observed RN 1 and LVN 1 transfer Resident 1 from the wheelchair to the bed, with the resident lifted from the armpit on both sides. Resident 1 was dependent on RN 1 and LVN 1 to perform the transfer and was not able to bear weight on both legs.
On 4/10/2024 at 11:12 a.m., during a concurrent observation and interview, Certified Nursing Assistant 1 (CNA 1) stated that she was transferring Resident 1 from the bed to the wheelchair alone and had asked the resident to stand up and adjust the resident's sitting position. CNA 1 demonstrated her position while Resident 1 was assisted. CNA 1 was observed standing behind Resident 1 with the wheelchair between CNA 1 and the resident. CNA 1 stated that she was holding Resident 1's pants and was not using an assistive device. CNA 1 stated that Resident 1 slipped, and she assisted the resident slide down from the wheelchair to the floor. CNA 1 stated she asked two other CNAs to help her put Resident 1 back on the wheelchair. CNA 1 stated that she informed RN 1 after Resident 1 was assisted back on the wheelchair. CNA 1 stated that she should not touch Resident 1 until RN 1 assessed the resident. CNA 1 stated that moving a resident that had a fall, before the resident was assessed, had the potential for the resident to sustain an injury or make an injury worst.
On 4/10/2024 at 11:51 a.m., during an interview, RN 1 stated that CNA 1 reported to him that Resident 1 had a witnessed and assisted fall. RN 1 stated that CNA 1 informed him there were no visible injuries on Resident 1. RN 1 stated he was informed that CNA 1 repositioned Resident 1 in the wheelchair when the resident slipped and CNA 1 assisted Resident 1 to the floor. RN 1 stated the registered nurse should ensure Resident 1 was assessed before moving or transferring the resident back to the wheelchair to ensure there were no injuries sustained from the fall. RN 1 stated that Resident 1 required a two person assist on transfers. RN 1 stated not assessing Resident 1 after the fall and moving the resident before the resident was assessed had the potential to cause serious injuries such as fractures.
On 4/10/2024 at 2:14 p.m., during a concurrent interview and record review, Resident 1's Physical Therapy (PT) Discharge summary, dated [DATE], was reviewed with the Director of Rehabilitation (DOR), indicated Resident 1 had a treatment diagnosis of abnormal posture. The DOR defined Resident 1's abnormal posture as asymmetrical and leaning towards the resident's affected, weaker, and dominant left side. The DOR stated that Resident 1 had a left side neglect (a deficit in awareness that occurs following an injury to the brain's right side). The Functional Skills Assessment section indicated that Resident 1's mobility on transfers were not tested. The DOR stated that Resident 1 was dependent on facility staff on transfers and required a Hoyer lift (a mechanical device used to lift and transfer a person with minimum physical effort) for safety.
On 4/10/2024 at 2:45 p.m., during an interview, the Director of Nursing (DON) stated that RN 1 should assess Resident 1 immediately after the fall. The DON stated that CNA 1 should not move a resident that fell until the RN had completed the assessment on the resident. The DON stated that Resident 1 had the potential for delayed treatment of injuries. The DON stated that the facility failed to follow the facility's protocol on addressing resident falls.
A review of the facility's policy and procedure titled, Assessing Falls and Their Causes, dated 5/2023, indicated the purpose to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. The policy indicated that after a fall, the resident would be evaluated for possible injuries to the head, neck, spine, and extremities. If there is evidence of injury, provide appropriate first aid and / or obtain medical treatment immediately.
A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, dated 5/2023, indicated that the facility promptly notifies the resident, the attending physician, and the resident representative of changes in the resident's medical and mental condition and / or status. The policy indicated that the nurse would notify the resident's attending physician or physician on call when there had been an accident or incident involving the resident. The policy indicated that prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form.
Feb 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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of five sampled residents (Reside...
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Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of five sampled residents (Resident 1).
This deficient practice had the potential to result in confusion in care and delivery of services to Resident 1 and may result in medication error.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 4/4/2023 with diagnoses that included encephalopathy (symptoms you experience when your brain is not working normally that can appear as confusion, memory loss, personality changes and or coma in the most severe form), type 2 diabetes mellitus ( characterized by high levels of sugar in the blood due to problem in the way the body regulates and uses sugar as a fuel), and left foot pain.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/27/2023, indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding).
A review of Resident 1's Physician's Order, dated 2/4/2024, indicated an order for hydromorphone hydrochloride (medication used to treat pain) tablet eight milligrams (mg - unit of measurement), give one tablet every four hours as needed for severe pain level of seven to ten (0 for no pain and 10- severe pain).
A review of Resident 1's Narcotic and Hypnotic Record dated 2/9/2024 indicated the resident was administeed with hydromorphone hydrochloride at 8 a.m. and 8: 30 a.m.
A review of Resident 1's Medication Administration Record (MAR-- record of medications received by the resident) indicated on 2/9/2024 at 8 a.m., the resident was medicated with hydromorphone hydrochloride for pain level of seven.
During a concurrent interview and record review on 2/23/2024 at 8:03 a.m., with the Assistant Director of nursing (ADON), Resident 1's Narcotic and Hypnotic Record dated 2/9/2024 and MAR dated 2/9/2024 was reviewed. The Narcotic and Hypnotic Record dated 2/9/2024 indicated the resident was administered with hydromorphone hydrochloride at 8 a.m. and 8: 30 a.m. The MAR dated 2/9/2024 indicated that at 8 a.m., the resident was administered with hydromorphone hydrochloride for pain level of seven. The ADON stated the nurse made a mistake in documenting the date. The ADON stated the 8:30 a.m. dose documented as given on 2/9/2024 should have been dated 2/8/2024.
During an interview on 2/23/2024 at 9:24 a.m., with the Director of Nursing (DON), the DON stated the nurse made an error in documenting the dates of administration of hydromorphone hydrochloride on the Narcotic and Hypnotic Record. The DON stated the nurse should have documented the administartion date and time of the medication accurately to prevent confusion in care.
A review of facility's policy and procedure titled, Charting and Documentation' undated and reviewed on 5/2023 indicated All services provided to the resident, progress toward the care plan goals, or ay changes in the residents medical, physical, functional, or psychosocial condition, shall be documented in the residents' medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.
Jan 2024
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 3) was treated with respect and dignity in a manner that promotes maintenance o...
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Based on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 3) was treated with respect and dignity in a manner that promotes maintenance or enhancement of the quality of life by failing to ensure the urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) drainage bag was fully covered by the dignity bag (a dark colored bag that conceals the front and back of the urine drainage bag).
This deficient practice had the potential to affect Resident 3 ' s sense of self-worth and self-esteem.
Findings:
A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 12/27/2023. Resident 3 ' s diagnoses included urinary tract infection (happen when bacteria enter the urethra [the tube through which urine leaves the body] and infect the urinary tract [the organs that make urine and removes it from the body]), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, was too high), and essential hypertension (abnormal blood pressure that was not a result of a medical condition).
A review of Resident 3 ' s Minimum Date Set (MDS – a standardized assessment and care screening tool), dated 1/832024, indicated the resident ' s cognition (mental action or process of acquiring knowledge and understanding) was intact.
A review of Resident 3 ' s Physician Order, dated 1/3/2024, indicated Foley catheter (a urinary catheter brand) connected to a urinary collection bag for urinary retention (a condition in which a person cannot empty all the urine from the bladder). The physician order also indicated to provide urinary catheter care every shift.
A review of Resident 3 ' s Care Plan on urinary catheter, dated 1/3/2024, indicated the resident had an indwelling urinary catheter related to urinary retention. The care plan intervention included urinary catheter care every shift.
On 1/25/2024 at 2 p.m., during a concurrent observation and interview, observed Resident 3 ' s urinary catheter hanging from the bed, visible to the people passing by the resident ' s room. Resident 3 ' s urinary catheter was not inside the dignity bag. Licensed Vocational Nurse 3 (LVN 3) stated that the urinary catheter drainage bag should be inside the dignity bag. LVN 3 stated that Resident 3 ' s dignity had the potential to be affected because of the resident ' s urinary catheter drainage bag was visible to other people.
On 1/25/2024 at 4:03 p.m., during an interview, the Director of Nursing (DON) stated that Resident 3 ' s urinary catheter drainage bag should be inside the dignity bag. The DON stated that the facility failed to make sure the urinary catheter was not exposed which had the potential to affect the resident ' s dignity.
A review of the facility ' s policy and procedure titled, Quality of Life – Dignity, dated 5/2023, indicated that each resident shall be cared for in a manner that promotes and enhances his sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. The policy indicated that demeaning practices and standards of care that compromise dignity are prohibited. Staff were expected to promote dignity and assist residents. The policy indicated an example of helping a resident to keep urinary catheter bags covered.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to promptly notify the attending physician (MD 1) on a change of condition after an unwitnessed fall incident that required physician interven...
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Based on interview and record review, the facility failed to promptly notify the attending physician (MD 1) on a change of condition after an unwitnessed fall incident that required physician intervention for one of ten sampled residents (Resident 2). On 1/29/2023, during the night shift (11 p.m. to 7 a.m. nursing shift), Resident 2 had an unwitnessed fall as reported to Licensed Vocational Nurse 1 (LVN 1) on the morning change of shift report. LVN 1 documented Resident 2 ' s fall on the Change of Condition Evaluation Form (COC) at 1:18 p.m. on 10/30/2023. Resident 2 ' s physician was notified at 6 p.m. on 10/30/2023.
This deficient practice had the potential for delayed medical interventions for Resident 2.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/12/2023. Resident 2 ' s diagnoses included chronic obstructive pulmonary disease (COPD – a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, was too high), and essential hypertension (abnormal blood pressure that was not a result of a medical condition).
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/19/2023, indicated the resident ' s cognitive (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions) skills was intact. The MDS indicated that Resident 2 required extensive assistance with two-person assist (resident involved in activity but staff provide weight-bearing support) on bed mobility, dressing, and personal hygiene.
A review of Resident 2 ' s COC, dated 10/30/2023, indicated that the resident was found on the floor during the night shift on 10/29/2023. The COC was documented at 1:18 p.m. on 10/30/2023 and the attending physician (MD 1) was notified at 6 p.m. on 10/30/2023.
A review of Resident 2 ' s Progress Notes, dated 10/30/2023, indicated that LVN 1 received the report from the night shift nursing staff that the resident had a fall. The time Resident 2 fell was not indicated on the documentation.
A review of Resident 2 ' s Physician Order, dated 10/30/2023, indicated that MD 1 was called at 1:15 p.m. and gave an order for 72-hours neuro check (an evaluation of a person ' s nervous system [brain, spinal cord, and a complex network of nerves]) for three days.
A review of Resident 2 ' s Progress Notes, dated 10/31/2023, Registered Nurse 1 (RN 1) indicated that Resident 2 was found sitting on the floor with the resident ' s back leaning against the bed.
On 1/25/2024 at 4:03 p.m., during a concurrent interview and record review, Resident 2 ' s COC and Progress Notes were reviewed with the Director of Nursing (DON). The DON stated that licensed nurses should have documented Resident 2 ' s unwitnessed fall immediately after the fall incident happened. The DON stated that the facility failed to timely notify Resident 2 ' s attending physician regarding the resident ' s unwitnessed fall. The DON stated that late notification to MD 1 had the potential for delayed treatment.
On 1/25/2024 at 5:11 p.m., during a telephone interview, RN 1 stated that Resident 2 was found sitting on the floor. RN 1 stated that she did not remember if Resident 2 ' s fall was documented or if MD 1 was notified. RN 1 stated that she would like to check Resident 2 ' s chart first before she answers more questions. The facility did not provide additional documents that indicated MD 1 was notified of Resident 2 ' s unwitnessed fall.
A review of the facility ' s policy and procedure titled, Change in a Resident ' s Condition or Status, dated 5/2023, indicated the facility shall promptly notify the resident, her attending physician, representative of changes in the resident ' s medical/mental condition and/or status. The policy indicated that the nurse would notify the resident ' s attending physician on call when there had been an accident or incident involving the resident. The policy indicated that the nurse would record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status.
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 F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure resident ' s pain was managed as indicated in the facility ' s Pain Assessment and Management policy for one of ten sampled resident...
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Based on interview and record review, the facility failed to ensure resident ' s pain was managed as indicated in the facility ' s Pain Assessment and Management policy for one of ten sampled residents (Resident 1), by failing to ensure Resident 1 ' s pain medication, oxycodone-acetaminophen (medication to manage moderate to severe pain) scheduled every 4 hours as needed, was administered according to the physician order.
This deficient practice resulted in Resident 1 ' s unnecessary pain experienced during daily activities and had the potential to lead to Resident 1 ' s decline in the quality of life.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/29/2020. Resident 1 ' s diagnoses included epilepsy (abnormal electrical brain activity), hemiplegia (one-sided muscle paralysis or weakness), and polyneuropathy (occurs when multiple peripheral nerves become damaged).
A review of Resident 1 ' s Care Plan on pain, revised on 7/20/2022, indicated that the resident had a pain on her left side of the body. The Care Plan interventions included to give analgesics as ordered by the physician. The Care Plan indicated to give oxycodone-acetaminophen 5-325 milligrams (mg – unit of measurement) two tablets every four hours as needed for severe or worst pain, 7 to 10 out of 10 on the pain scale (a numerical method to measure the level of pain with 0 being no pain to 10 being the worst pain).
A review of Resident 1 ' s History and Physical, dated 9/4/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 12/29/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact.
A review of Resident 1 ' s Medication Administration Record (MAR), dated 1/2024, indicated that on 1/10/2024, the resident was given two tablets of oxycodone-acetaminophen 5-325 mg at 1:30 p.m. for a pain level of eight out of ten. Resident 1 was given two tablets of oxycodone-acetaminophen 5-325 mg at 6:10 p.m., 40 minutes after the pain medication may be given, for a pain level of eight out of ten. Resident 1 was given two tablets of oxycodone-acetaminophen 5-325 mg at 1:30 a.m. on 1/11/2024, three hours and 20 minutes after the pain medication may be given, for a pain level of eight out of ten.
A review of Resident 1 ' s Progress Notes, dated 1/10/2024, indicated that the resident ' s pharmacy had not delivered the oxycodone-acetaminophen medication for Resident 1. The progress notes indicated that Resident 1 requested for the pain medication at 4:30 p.m. and was informed that there was only one tablet left. The pain medication was not given to Resident 1. The progress notes indicated that at 6:10 p.m., Resident 1 received two tablets of oxycodone-acetaminophen medication taken from the emergency kit.
On 1/25/2024 at 10:30 a.m., during an interview, Resident 1 stated that she had to wait for hours in pain before her pain medication was given because the nursing staff did not order her medications on time. Resident 1 stated that she had to tell the nursing staff to get the medication from the emergency kit and only then Resident 1 was able to get the pain medication. Resident 1 stated that when she did not get her pain medications on time, her pain becomes worst and harder to control. Resident 1 stated that she should not suffer in pain.
On 1/25/2024 at 2:44 p.m., during a concurrent interview and record review, Resident 1 ' s MAR was reviewed with Licensed Vocational Nurse 1. The MAR indicated that on 1/10/2023, Resident 1 received two tablets of oxycodone-acetaminophen 5-325 mg at 1:30 p.m. and at 6:10 p.m. The MAR indicated that on 1/11/2024 at 1:30 a.m., Resident 1 received two tablets of oxycodone-acetaminophen 5-325 mg. LVN 1 stated that she called Resident 1 ' s pharmacy and was informed that the pharmacy did not receive the resident ' s medication refill request. LVN 1 stated that she sent another medication refill request to Resident 1 ' s pharmacy. LVN 1 stated that licensed nurses should follow up the requested medication refill from the pharmacy to make sure it was received to prevent delay in medication administration.
On 1/25/2024 at 4:03 p.m., during an interview, the Director of Nursing stated that licensed nurses should request for the resident ' s medication refill three to five days before the medication supply runs out. The DON stated that licensed nurses may get a medication from the emergency kit until the requested medication refill arrive from the pharmacy. The DON stated that there was a delay in administering Resident 1 ' s pain medications and had the potential for the resident to experience more pain.
A review of the facility ' s policy and procedure titled, Pain Assessment and Management, dated 5/2023, indicated the purpose to help the staff identify pain in the resident, and to develop interventions that were consistent with the resident ' s goals and needs and that address the underlying causes of pain.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure pain medications were available for one of ten sampled residents (Resident 1) by failing to acquire Resident 1 ' s pain medication, ...
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Based on interview and record review, the facility failed to ensure pain medications were available for one of ten sampled residents (Resident 1) by failing to acquire Resident 1 ' s pain medication, oxycodone-acetaminophen (medication to manage moderate to severe pain) scheduled every 4 hours as needed, as indicated in the facility ' s policy on medication refill.
This deficient practice resulted in Resident 1 ' s unnecessary pain experienced during daily activities and had the potential to lead to Resident 1 ' s decline in the quality of life.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/29/2020. Resident 1 ' s diagnoses included epilepsy (abnormal electrical brain activity), hemiplegia (one-sided muscle paralysis or weakness), and polyneuropathy (occurs when multiple peripheral nerves become damaged).
A review of Resident 1 ' s Care Plan on pain, revised on 7/20/2022, indicated that the resident had a pain on her left side of the body. The Care Plan interventions included to give analgesics as ordered by the physician. The Care Plan indicated to give oxycodone-acetaminophen 5-325 milligrams (mg – unit of measurement) two tablets every four hours as needed for severe or worst pain, 7 to 10 out of 10 on the pain scale (a numerical method to measure the level of pain with 0 being no pain to 10 being the worst pain).
A review of Resident 1 ' s History and Physical, dated 9/4/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 12/29/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact.
A review of Resident 1 ' s Medication Administration Record (MAR), dated 1/2024, indicated that on 1/10/2024, the resident was given two tablets of oxycodone-acetaminophen 5-325 mg at 1:30 p.m. for a pain level of eight out of ten. Resident 1 was given two tablets of oxycodone-acetaminophen 5-325 mg at 6:10 p.m., 40 minutes after the pain medication may be given, for a pain level of eight out of ten. Resident 1 was given two tablets of oxycodone-acetaminophen 5-325 mg at 1:30 a.m. on 1/11/2024, three hours and 20 minutes after the pain medication may be given, for a pain level of eight out of ten.
A review of Resident 1 ' s Progress Notes, dated 1/10/2024, indicated that the resident ' s pharmacy had not delivered the oxycodone-acetaminophen medication for Resident 1. The progress notes indicated that Resident 1 requested for the pain medication at 4:30 p.m. and was informed that there was only one tablet left. The pain medication was not given to Resident 1. The progress notes indicated that at 6:10 p.m., Resident 1 received two tablets of oxycodone-acetaminophen medication taken from the emergency kit.
On 1/25/2024 at 2:44 p.m., during a concurrent interview and record review, Resident 1 ' s MAR was reviewed with Licensed Vocational Nurse 1. The MAR indicated that on 1/10/2023, Resident 1 received two tablets of oxycodone-acetaminophen 5-325 mg at 1:30 p.m. and at 6:10 p.m. The MAR indicated that on 1/11/2024 at 1:30 a.m., Resident 1 received two tablets of oxycodone-acetaminophen 5-325 mg. LVN 1 stated that she called Resident 1 ' s pharmacy and was informed that the pharmacy did not receive the resident ' s medication refill request. LVN 1 stated that she sent another medication refill request to Resident 1 ' s pharmacy. LVN 1 stated that licensed nurses should follow up the requested medication refill from the pharmacy to make sure it was received to prevent delay in medication administration.
On 1/25/2024 at 4:03 p.m., during an interview, the Director of Nursing stated that licensed nurses should request for the resident ' s medication refill three to five days before the medication supply runs out. The DON stated that there was a delay in administering Resident 1 ' s pain medications and had the potential for the resident to experience more pain.
A review of the facility ' s policy and procedure titled, Pain Assessment and Management, dated 5/2023, indicated the purpose to help the staff identify pain in the resident, and to develop interventions that were consistent with the resident ' s goals and needs and that address the underlying causes of pain.
A review of the facility ' s policy and procedure titled, Transmitting Medication Orders, dated 5/2023, indicated that the nursing
staff may communicate new, refill, or change of medication orders to a registered pharmacist. The refill orders section of the policy indicated that reorder medications when a three to five-day supply remains in the medication storage.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of ten sampled residents (Resident 2). On 1/29/2023, during the nigh...
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Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of ten sampled residents (Resident 2). On 1/29/2023, during the night shift (11 p.m. to 7 a.m. nursing shift), Resident 2 had an unwitnessed fall as reported to Licensed Vocational Nurse 1 (LVN 1) on the morning change of shift report. LVN 1 documented Resident 2 ' s fall on the Change of Condition Evaluation Form (COC) at 1:18 p.m. on 10/30/2023. Resident 2 ' s physician was notified at 6 p.m. on 10/30/2023. Registered Nurse 1 (RN 1) documented Resident 2 ' s fall on 10/31/2023.
This deficient practice resulted in inaccurate information on Resident 2 ' s clinical record and had the potential for delayed medical interventions for Resident 2.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/12/2023. Resident 2 ' s diagnoses included chronic obstructive pulmonary disease (COPD – a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, was too high), and essential hypertension (abnormal blood pressure that was not a result of a medical condition).
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/19/2023, indicated the resident ' s cognitive (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions) skills was intact. The MDS indicated that Resident 2 required extensive assistance with two-person assist (resident involved in activity but staff provide weight-bearing support) on bed mobility, dressing, and personal hygiene.
A review of Resident 2 ' s COC, dated 10/30/2023, indicated that the resident was found on the floor during the night shift on 10/29/2023. The COC was documented at 1:18 p.m. on 10/30/2023 and the attending physician (MD 1) was notified at 6 p.m. on 10/30/2023.
A review of Resident 2 ' s Progress Notes, dated 10/30/2023, indicated that LVN 1 received the report from the night shift nursing staff that the resident had a fall. The time Resident 2 fell was not indicated on the documentation.
A review of Resident 2 ' s Progress Notes, dated 10/31/2023, Registered Nurse 1 (RN 1) indicated that Resident 2 was found sitting on the floor with the resident ' s back leaning against the bed.
On 1/25/2024 at 4:03 p.m., during a concurrent interview and record review, Resident 2 ' s COC and Progress Notes were reviewed with the Director of Nursing (DON). The DON stated that licensed nurses should have documented Resident 2 ' s unwitnessed fall immediately after the fall incident happened. The DON stated that the facility failed to properly and timely document Resident 2 ' s fall. The DON stated that late and inaccurate documentation of a resident ' s COC had the potential for delayed treatment.
On 1/25/2024 at 5:11 p.m., during a telephone interview, RN 1 stated that Resident 2 was found sitting on the floor. RN 1 stated that she does not remember if Resident 2 ' s fall was documented or if MD 1 was notified. RN 1 stated that she would like to check Resident 2 ' s chart first before she answers more questions. The facility did not provide additional documents that indicated Resident 2 ' s fall was documented timely.
A review of the facility ' s policy and procedure titled, Change in a Resident ' s Condition or Status, dated 5/2023, indicated the facility shall promptly notify the resident, her attending physician, representative of changes in the resident ' s medical/mental condition and/or status. The policy indicated that the nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is ...
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Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for three of ten sampled residents (Resident 5, Resident 7, and Resident 8) by failing to:
1. Ensure Housekeeping 1 [HKP 1], Activity Assistant 1 [AA 1], Patio Supervisor [PS], and Payroll Personnel [PRL 1]) wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly.
2. Ensure that a used facemask was not placed on a clean kitchen surface.
These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19.
Findings:
On 1/25/2024 at 9:20 a.m., during a concurrent observation and interview, observed HKP 1 ' s N95 mask was not properly worn. The elastic straps of HKP 1 ' s N95 mask were both on the lower back of the neck with visible space between the nose bridge and the N95 mask. HKP 1 stated that one of the N95 mask ' s elastic straps should be on top of the head and one the neck. HKP 1 was observed adjusting the elastic straps of her N95 mask. HKP 1 stated that not wearing the N95 mask properly had the potential to spread infections to the residents and staff.
On 1/25/2024 at 9:36 a.m., during a concurrent observation and interview, observed AA 1 ' s N95 mask was not properly worn. AA 1 ' s N95 mask did not have the bottom elastic strap and had a space between his chin and the N95 mask. AA 1 touched the N95 mask and pushed it up to cover his nose. AA 1 stated that the elastic strap broke and he was going to change it later. AA 1 stated that N95 masks not worn properly had the potential to spread infection to residents and staff.
A review of Resident 7 ' s admission Record indicated the facility admitted the resident on 1/17/2020. Resident 7 ' s diagnoses included epilepsy (abnormal electrical brain activity), hemiplegia (one-sided muscle paralysis or weakness), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
A review of Resident 7 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 12/27/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired.
A review of Resident 8 ' s admission Record indicated the facility admitted the resident on 1/17/2020. Resident 8 ' s diagnoses included pneumonia (an infection of the lungs that may be caused by bacteria, virus, or fungi), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, was too high), and essential hypertension (abnormal blood pressure that was not a result of a medical condition).
A review of Resident 8 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 12/22/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired.
On 1/25/2024 at 9:45 a.m., during a concurrent observation and interview, observed PS 1 ' s N95 mask was not properly worn. The elastic straps of PS 1 ' s N95 mask were both on the lower back of the neck with visible space between PS 1 ' s jaw and the N95 mask. PS 1 assisted Resident 7 and Resident 8 in the facility ' s smoking patio. PS 1 was observed talking to Resident 7 and Resident 8 while PS 1 ' s N95 mask was not properly worn. PS 1 stated that the elastic straps of the N95 mask should be on top of the head and on the neck. PS 1 stated that he sometimes takes the elastic strap of the N95 mask down to the neck because the cigarette smoke goes in the N95 mask and caused him difficulty breathing. PS 1 stated that not wearing the mask properly had the potential to spread infection such as Covid-19 to other residents.
On 1/25/2024 at 10:14 a.m., during a concurrent observation and interview, observed a used blue facemask on top of a stack of disposable trays on the kitchen countertop. The facemask was observed unfolded and had the contour of the wearer ' s nose. The disposable tray had packets of salt, pepper, plastic fork and was beside the unpeeled bananas. The Dietary Supervisor (DS) stated that the facemask appeared used and should be disposed in the trash can. The DS stated that not disposing used masks properly had the potential to contaminate the surroundings and spread infection to staff and residents.
A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 9/19/2020. Resident 5 ' s diagnoses included type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, was too high), aphasia (a disorder that affects how a person communicate), and schizophrenia (a serious mental illness that affects how a person think, feel, and behave.
A review of Resident 5 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 12/8/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired.
On 1/25/2024 at 10:53 a.m., during a concurrent observation and interview, observed PRL 1 came out of Resident 5 ' s room. PRL 1 wore the N95 mask using only the top elastic strap. PRL 1 had the bottom elastic strap of the N95 mask hanging and there was a visible gap between her face and the N95 mask. PRL 1 stated that the N95 mask elastic straps should be worn with one elastic strap on top of the head and one on the neck. PRL 1 stated that not wearing the N95 mask properly had the potential to spread the infection such as Covid-19 to other residents and staff. PRL 1 adjusted her N95 mask.
On 1/25/2024 at 3:21 p.m., during an interview, the Infection Preventionist Nurse (IPN) stated that N95 masks should be worn with one elastic strap on the top of the head and one on the neck with a snug fit on the face. The IPN stated that used facemasks should be disposed properly to prevent cross contamination (a transfer of harmful bacteria from one person, object, or place to another). The IPN stated that N95 mask not properly worn had the potential to spread infection such as Covid-19 to residents and staff.
A review of the facility ' s policy and procedure titled, Coronavirus Disease (Covid-19) – Infection Prevention and Control Measures, dated 5/2023, indicated the facility follows recommended standard and transmission precautions, environmental cleaning, and social distancing practices to prevent the transmission of Covid-19 within the facility. The policy included the Center for Disease Control (CDC) standards on donning (putting on) a mask or respirator. The policy indicated to secure elastic bands at the middle of the head and on neck, fit flexible band to nose bridge, fit snug to face and below chin, and fit check the respirator.
A review of the facility ' s policy and procedure titled, Infection Control, dated 5/2023, indicated the facility ' s infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections.
Dec 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1), who needed an ind...
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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 six sampled residents (Resident 1), who needed an indwelling urinary catheter (a flexible plastic tube [a catheter] inserted into the bladder [a hollow organ that stores urine] to provide continuous urinary drainage) because of a diagnosis of urinary retention (inability to voluntarily void urine), was provided treatment and care based on the comprehensive assessment and plan of care. The facility failed to:
1. Monitor the amount of urine eliminated (urinary output) after Resident 1 ' s urinary catheter was pulled out and was not replaced on 11/3/2023, as ordered by Resident 1 ' s attending physician (Physician 1).
2. Inform Physician 1 that the facility did not have policies and procedures (P&Ps) on monitoring the urinary output on incontinent (unable to control voiding) residents.
3. Utilize a bladder scanner (ultrasound device that uses sound waves to determine how much urine is in the bladder) the facility had but there was no P&P to guide the licensed nurses on its use and the licensed nurses were not trained on its use.
As a result, on 11/14/2023, during a urologist (medical doctor specialized in the study and treatment of the function and diseases of the urinary system) consult, Urologist 1 drained a total of eight (8) liters (8,000 milliliters [ml – unit of measurement]) of urine in the bladder (men ' s bladder maximum capacity is approximately 700 ml) from Resident 1 bladder. From his office, Urologist 1 sent Resident 1 to General Acute Care Hospital 1 (GACH 1) emergency room (ER), where Resident 1 was diagnosed with obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) most likely due to prostatomegaly (enlargement of the prostate gland [located just below the bladder and surrounds the top portion of the tube that drains urine from the bladder, the urethra]). Other diagnoses were acute kidney injury (condition in which the kidneys suddenly cannot filter waste from the blood) and status post bladder decompression (use of a catheter to continuously release urine from the bladder).
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident as a new admission on [DATE]. Resident 1 ' s diagnoses included pneumonia (inflamed or swollen lung tissue caused by infection with a germ) for continued antibiotic therapy, autism (serious developmental disorder that impairs the ability to communicate and interact), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and benign prostatic hyperplasia (BPH – a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream).
A review of Resident 1 ' s Baseline Care Plan, dated 11/2/2023, indicated on the bowel and bladder section that the resident had an indwelling (inside the body) catheter. There was no documented intervention for Resident 1 ' s indwelling catheter.
A review of Resident 1 ' s Care Plan for the use of the indwelling urinary catheter, initiated on 11/2/2023, indicated the goal was for Resident 1 to be free from catheter related trauma. The intervention included monitoring and documenting the intake (amount of fluid consumed) and the output as per facility ' s policy.
A review of Resident 1 ' s Catheter Evaluation, dated 11/2/2023, indicated the resident was admitted with an indwelling catheter. The justification for the catheter indicated Resident 1 ' s inability to manage urinary retention or incontinence with intermittent catheterization (these catheters are inserted several times a day for just long enough to drain your bladder, and then removed).
A review of the Physician ' s Order for Resident 1, dated 11/2/2023, indicated Lasix (a water pill that makes the person urinate more) 40 milligrams (mg – unit of measurement) one tablet by mouth two times a day.
A review of Resident 1 ' s Change in Condition (COC) Evaluation, dated 11/3/2023, indicated Resident 1 ' s indwelling urinary catheter was (accidentally) pulled out and Resident 1 ' s urinary retention would make his condition worse and increasing the fluid intake would make the condition better. The COC indicated Physician 1 was notified and Physician 1 ordered to discontinue Resident 1 ' s indwelling urinary catheter and monitor him for urinary retention.
A review of Resident 1 ' s Progress Notes, dated 11/3/2023, indicated the resident ' s urinary catheter was pulled out, Physician 1was notified and ordered monitoring Resident 1 for urinary retention for 72 hours.
A review of Resident 1 ' s Care Plan initiated on 11/3/2023, indicated Resident 1 ' s indwelling urinary catheter was pulled out. The care plan interventions included monitoring Resident 1 for bleeding, pain, and for urinary retention. The manner for nursing staff to monitor Resident 1 ' s for urinary retention was not indicated in the care plan.
A review of Resident 1 ' s Progress Notes, dated 11/4/2023, indicated nursing was monitoring Resident 1 for urinary retention. There was no documented evidence of the amount of urine Resident 1 had eliminated (urine output).
A review of Resident 1 ' s Progress Notes, dated 11/5/2023 and 11/6/2023, indicated nursing was monitoring Resident 1 for urinary retention. The progress notes indicated that Resident 1 ' s wet disposable brief was changed two times with no foul-smelling yellow output on the disposable brief. There was no documented evidence of the amount of urine Resident 1 had eliminated (urine output) and no documented evidence the incontinent brief was weighed before (clean) and after to estimate the volume of urine. According to the National Institutes of Health (www.ncbi.nih.gov), individual diapers are typically weighed prior to patient application and then this value is subtracted from the wet weight; the mass of one liter is equivalent to on kilogram of weight.
A review of Resident 1 ' s undated Bowel and Bladder 72 Hour Toileting Diary indicated there was no documented output during the 72-hour monitoring from the time of the order on 11/3/2023 to 11/6/2023.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/13/2023, indicated the resident ' s cognition (involving conscious intellectual activity such as thinking, reasoning, or remembering) was severely impaired. The MDS indicated that Resident 1 was dependent on staff for bed mobility, transfers, personal hygiene, and toilet use.
Resident 1 was assessed as incontinent of urine.
A review of the Recapitulation of Stay and Discharge summary, dated [DATE], indicated Resident 1 was discharged to prior living arrangement (lower level of care) per Responsible Party (RP) request. The summary section for Overall Summary of Discharge indicated Resident 1 improved and no longer needed the services of the facility.
A review of Resident 1 ' s Patient Summary from a Urology Clinic indicated the resident was seen on 11/14/2023 at 11 a.m. with the diagnosis of BPH with lower urinary tract symptoms, retention of urine, and cystitis (inflammation of the bladder). Urologist 1 documented the follow up visit was because Resident 1 had abdominal distention and was not feeling well. Urologist 1 indicated that an indwelling urinary catheter was placed in Resident 1 which drained eight liters of urine output. The Patient Summary also indicated that Resident 1 was sent to the emergency room for evaluation.
A review of Resident 1 ' s GACH 1 Emergency Documentation – MD, dated 11/14/2023 at 3:22 p.m., indicated the resident presented at the emergency room with a complaint of urinary retention. Urologist 1 placed an indwelling urinary catheter with eight liters output. Resident 1 was admitted as an inpatient in GACH 1.
A review of Resident 1 GACH 1 Inpatient Discharge summary, dated [DATE], indicated the resident was discharged from GACH 1 to home on [DATE] with diagnoses including obstructive uropathy most likely due to prostatomegaly complicated by acute kidney injury and status post bladder decompression.
On 11/17/2023 at 8:29 a.m. during an interview, RP stated she requested Resident 1 discharge from the facility because she felt they were not taking good care of Resident 1. RP stated that on 5/2023 (prior to Resident 1 ' s admission to the facility), Resident 1 was hospitalized because of urinary retention and Urologist 1 informed RP that Resident 1 needed the indwelling urinary catheter for the rest of his life. RP stated that once Resident 1 was discharged , she contacted Urologist 1 ' s office for him to evaluate Resident 1, who was not well and had abdominal pain.
On 11/20/2023 at 11:27 a.m., during an interview with Licensed Vocational Nurse 1 (LVN 1) and a review of Resident 1 ' s clinical record, LVN 1 stated that Resident 1 ' s 72-hour monitoring for urinary retention should have been documented but LVN 1 was unable to find it. LVN 1 stated she did not document the sign and symptoms of urinary retention and did not describe Resident 1 ' s disposable brief saturation with urine. LVN 1 stated that Resident 1 was admitted for antibiotic treatment and resident had an indwelling urinary catheter, but she did not know the reason for the catheter. LVN 1 stated certified nursing assistants (CNAs) would report to her how many times the resident ' s disposable brief was changed. LVN 1 was not able to answer how the amount of output was determined to identify that Resident 1 was or not retaining urine. LVN 1 stated that they do not weigh or describe the saturation of the disposable briefs.
On 11/20/2023 at 2:52 p.m., an interview with the Director of Nursing (DON) and a concurrent review of Resident 1 ' s clinical was conducted. A review of the Intake and Output Record after Resident 1 ' s indwelling urinary catheter indicated that at 7 a.m. to 3 p.m., Resident 1 voided (urinated) three times. The record indicated that at 3 p.m. to 11 p.m., Resident 1 voided two times. There were no other documented intake and output amount. The DON stated Resident 1 should be monitored for urinary retention for 72 hours after the urinary catheter was removed and document the resident ' s intake and output in the medical record. The DON stated licensed nurse should have monitored Resident 1 ' s output by describing the urine saturation in the disposable brief or ideally staff should have used a bladder scanner (used to measure the amount of urine in the bladder). The DON stated she was unsure where the bladder scanner was, and it was probably at another Nursing Station. The DON was unable to provide P&Ps on intake and output, measuring output on an incontinent resident, or the use of a bladder scanner. The DON was unable to provide documented evidence the licensed nurses were trained on the use of the bladder scanner.
On 11/20/2023 at 4:16 p.m., during a telephone interview, the ADON stated that if the resident had an indwelling urinary catheter pulled out accidentally or removed (discontinued), the nurses would initiate the COC and monitor for urinary retention for 72 hours every shift. If the resident did not have an output in the first 4-6 hours after catheter removal, the charge nurse would call the doctor. The ADON stated CNAs should report to the charge nurse how many incontinent briefs were changed and the saturation of the disposable briefs. The ADON stated the facility had a bladder scanner but was unsure if it was working or calibrated.
On 12/12/2023 at 11:15 a.m., during a telephone interview, Urologist 1 stated Caretaker brought Resident 1 to his office and that was the best thing that happened to Resident 1 because he (Urologist 1) inserted an indwelling urinary catheter and drained 8 liters at one time. Urologist 1 stated Resident 1 should never have been without the indwelling urinary catheter due to urinary retention, and he should have been contacted immediately for him to insert a new one. Urologist 1 stated Resident 1 ' s urine was flowing back to the kidneys and was causing damage.
A review of the facility ' s policy and procedure titled, Charting and Documentation, dated 5/2023, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional, or psychosocial condition, shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care.
A review of the facility ' s policy and procedure titled, Acute Condition Changes – Clinical Protocol, dated 5/2023, indicated that the staff will monitor and document the resident ' s progress and responses to treatment. It also indicated that direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the nurse.
Nov 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a safe environment and supervision for one of four 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 provide a safe environment and supervision for one of four resident (Resident 1).
On 6/23/2023 at 10:40 a.m. Resident 1, while unsupervised, was walking out of room became dizzy and fell. Resident 1 was observed with laceration (cut) to forehead and sent to General Acute Care Hospital 1 (GACH 1).
On 6/24/2023 at 7:17 a.m. Resident 1 returned to facility. At 8:18 a.m. Resident 1 was found in her room lying on her left side with reopened wound on left forehead and bleeding, Resident 1 was transferred to GACH 2.
As a result, Resident 1 fell and sustained a laceration on the left side of the forehead requiring transfer to GACH 2 where she was diagnosed with cervical vertebra fracture (C2 fracture- a break in the second vertebra [the small circular bones that form the spine of a human being or animal] of your neck).
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 12/26/2020 and readmitted the resident on 6/24/2023 with diagnosis that included encephalopathy (damage or disease that affects the brain), difficult in walking, muscle wasting and atrophy (decrease in size of an organ or tissue; wasting), and vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain).
A review of Resident 1 ' s Fall Risk assessment dated [DATE] indicated Resident 1 had a score of 5 (total score of 10 or greater, the resident should be considered at high risk for potential falls).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/12/2023 indicated the resident was able to understand and be understood. Resident 1 required supervision with bed mobility, transfer, walking in room and corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene.
A review of Resident 1's Change of Condition Evaluation (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains documentation), dated 5/29/2023, indicated resident had a fall and sustained a lump to right forehead, skin intact.
A review of Resident 1 ' s Care plan developed on 5/30/2023 for fall found on floor on 5/29/2023 sustained right forehead skin discoloration. The intervention included answer call light in timely manner, may keep the bed in lowest position, except when resident is out of bed or during care or fall precaution, every shift.
A review of Resident 1 ' s Fall Risk assessment dated [DATE] indicated Resident 1 had a score of 14 (total score of 10 or greater, the resident should be considered at high risk for potential falls).
A review of the Physician ' s Orders for Resident 1 dated 6/7/2023 indicated apply sensor pad alarm in bed to remind the resident to call for assistance and alert staffs when moving or getting up from bed every shift.
A review of Resident 1's COC Evaluation dated 6/23/2023 at 10:40 a.m. indicated resident was found walking out of her room towards the front of building. Two Certified Nursing Assistants (CNAs) were walking towards Resident 1 but did not make it to her in time, Resident 1 got dizzy and that is what caused her to fall. Registered Nurse Supervisor assessed resident and observed a cut to Resident 1 ' s forehead.
A review of the Physician ' s Orders for Resident 1 dated 6/23/2023 indicated transfer to GACH 1 for further evaluation due to fall and hitting head.
A review of Resident 1 ' s Nursing Home to Hospital Transfer Form dated 6/23/2023 indicated resident transferred to GACH 1 due to fall.
A review of Resident 1 ' s Care plan developed on 6/23/2023 for fall found on the floor, resident felt dizzy and fell. The intervention included assist resident to wheelchair transfer to bed, body assessment noted with laceration on forehead initial treatment rendered, and doctor notified with new order to transfer resident to acute hospital.
A review of Resident 1 ' s Care plan developed on 6/23/2023 resident is high risk for minor injury/major or serious injury such sustain fracture and head injury r/t multiple falls in the last 90 days, poor balance or control, poor communication/comprehension, attempt to get up from bed/wheelchair unassisted, unaware of safety needs, impaired balance, altered thought process, impaired cognition, get up from bed unassisted, not using the call light for assistance for mobility, transfer and toilet needs, forgetfulness and confusion. The interventions included anticipate and meet the residents needs, apply sensor pad alarm in bed to remind resident to call for assistance and alert staffs when moving or getting up from bed every shift.
A review of Resident 1 ' s nursing Progress Note dated 6/24/2023 at 7:17 a.m. indicated hospice and Family Member (FM 1) made aware of Resident 1 ' s return to facility.
A review of Resident 1 ' s COC Evaluation dated 6/24/2023 at 8:18 a.m. indicated resident found lying on her left side on the floor. Resident 1 noted with reopened wound on left forehead and bleeding.
A review of Resident 1 ' s nursing Progress Note dated 6/24/2023 at 8:40 a.m. indicated at around 8:20 a.m. Resident 1 had a fall, was laying on left side and was covered with blood on head from a new laceration.
A review of the Physician ' s Orders for Resident 1 dated 6/24/2023 indicated transfer to GACH 2 for further evaluation due to fall and hitting head.
A review of Resident 1 ' s Nursing Home to Hospital Transfer Form dated 6/24/2023 indicated resident transferred to GACH 2 due to fall.
A review of Resident 1 ' s Fall Risk assessment dated [DATE] indicated Resident 1 had a score of 14 (total score of 10 or greater, the resident should be considered at high risk for potential falls).
A review of Resident 1 ' s GACH 2 Hospital Discharge Summary indicated Resident 1 was admitted on [DATE] and discharged from GACH 2 on 7/1/2023. The Discharge Summary indicated Resident 1 had significant left frontal scalp soft tissue swelling, hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel) with laceration and evidence of C2 fracture.
During an interview on 11/14/2023 at 3:15 p.m. with Certified Nursing Assistant 3 (CNA 3) stated on 6/23/2023 she heard bed alarm going off and saw Resident 1 walking in hallway coming out of her room. CNA 3 stated Resident 1 was about three steps away from her when she fell. CNA 3 stated Resident 1 fell sideways and hit the floor causing a laceration to her forehead. CNA 3 stated the following day (6/24/2023) was told by another staff that Resident 1 had fallen and when CNA 3 went to see Resident 1 the charge nurse was already there. CNA 3 stated Resident 1 had reopened the laceration, there was blood. The CNA 3 stated Resident 1 ' s room was not near the nurses ' station; it would have been beneficial for Resident room to be close to nurses ' station.
During an interview on 11/14/2023 at 4:15 p.m. with the Assistant Director of Nursing (ADON) stated Resident 1 was on the falling star program which means the resident is a fall risk, those residents get a star on their front door, wheelchair and back of bed so that staff are aware the resident is at risk for falls. The ADON stated resident will be placed near nurses ' station, use bed alarms if applicable and have constant visualization of the resident. The ADON stated Resident 1 ' s room was not near the nurses ' station, but it was in a visible area. The ADON stated Resident 1 had a fall on 6/23 was sent to hospital and then returned on 6/24. The ADON stated could have provided one on one for the resident due to the frequency of falls. The ADON stated not moving Resident 1 ' s room close to nursing station and not providing one on one to the resident placed the resident at risk to continue to have falls and was a risk for injury.
During an interview on 11/14/2023 at 4:55 p.m. with the Administrator (Adm) stated typical interventions when a resident has a fall is to move the resident room and review their medications. The Adm stated Resident 1 may have benefited from a one on one to prevent falls. The Adm stated Resident 1 ' s room was no changed and the facility did not provide one on one for the resident.
A review of the facility ' s current policy and procedure titled, Falls and Fall Risk, Managing, revised date of 3/2018, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 1) to address resident ' s ref...
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Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 1) to address resident ' s refusal for nail care.
This deficient practice had the potential to negatively affect Resident 1 ' s self-esteem and placed him at risk for infection.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/12/2021 with diagnoses that included bilateral osteoarthritis (joint disease in which the tissues in the joint, break down over time) of knee, repeated falls, seizures (a sudden, uncontrolled burst of electrical activity in the brain causing changes in behavior, movements and feelings) and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain).
A review of Resident 1 ' s History and Physical, dated 9/14/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/14/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required extensive assistance from staff for all activities of daily living (ADL- bed mobility, dressing, toilet use and personal hygiene).
During a concurrent observation and interview on 10/25/2023, at 10:17 a.m., with Certified Nursing Assistant 1 (CNA 1), inside the physician ' s room, observed Resident 1 ' s nails were long and thick. CNA 1 stated resident refuses to trim his nails and nurses were notified.
During a concurrent interview and record review on 10/25/2023, at 10:19 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 1 ' s Care Plans, were reviewed. LVN 1 stated no care plan was developed to address Resident 1's refusal for nail care. LVN 1 stated residents nails should be trimmed for hygiene and safety issues.
During an interview on 10/25/2023 at 11:44 a.m., the Director of Nursing (DON) stated CNA 1 should have reported that resident refuses to trim his nail so care plan can be developed to address his refusal.
A review of facility ' s policy and procedure titled, Comprehensive Person-Centered Care Plans, dated 12/2016 and reviewed on 5/2023 indicated, The comprehensive, person-centered care plan will.
g. Incorporate identified problem areas.
h. Incorporate risk factors associated with identified problems.
j. Reflect the resident ' s expressed wishes regarding care and treatment goals.
Oct 2023
29 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 coordinated group of experts fro...
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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 coordinated group of experts from several different fields who work together) failed to determine if self-administration was clinically appropriate for two of two sampled (Resident 89 and Resident 62) residents investigated under the self-administer medications care area by failing to:
a. Ensure that the self-administration of medication assessment was completed for Resident 89.
b. Ensure the medications were not left at the bedside for Resident 62, who was not capable to self-administer medications investigated under the self-administer medications care area.
These deficient practices placed the resident at risk for unsafe medication administration or omission.
Findings:
a. A review of Resident 89's admission Record indicated the facility admitted the resident on 11/11/2021 and readmitted on [DATE] with diagnoses including diabetes mellitus type 2 (a condition that occurs when the blood sugar is too high), lumbar radiculopathy (a disorder that causes pain in the lower back and hip which radiates down the back of the thigh into the leg), and difficulty walking.
A review of Resident 89's History and Physical dated 11/22/2022 indicated the resident had the capacity to understand and make decisions.
A review of Resident 89's Minimum Data Set (MDS - an assessment and care screening tool) dated 8/17/2023, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision from staff with eating, totally dependent on staff with transfers, and bathing, and extensive assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a concurrent observation and interview on 10/2/2023 at 2:00 p.m., observed a medicine cup containing crushed medications on top of the Resident 89's overbed table. Resident 89 stated he requested for nurses to leave her medications on top of the overbed table because she takes the medications slowly. Resident 89 stated the medications in the cup included pain and muscle relaxant medications.
During a concurrent interview and record review on 10/4/2023 at 2:00 p.m., Licensed Vocational Nurse 1 (LVN 1) verified there was no documented evidence that the self-administration of medication assessment was completed prior to leaving medications at bedside for Resident 89 to self-administer. LVN 1 stated allowing the resident to self-administer medications without an assessment was a safety issue.
During a concurrent interview and record review on 10/5/2023 at 3:19 p.m., reviewed Resident 89's medical records with Quality Assurance (QA) nurse. The QA nurse verified there was no documented evidence that the self-administration of medication assessment was completed.
During an interview on 10/4/2023 at 4:10 p.m., the Director of Nursing (DON) stated the licensed nurses were supposed to wait at the bedside until all medications were administered for resident safety. The DON stated the self-administration of medication assessment should have been completed prior to leaving any medication at the bedside for any residents for safety.
b. A review of Resident 62's admission Record indicated Resident 62 the facility admitted the resident to the facility on [DATE] with diagnoses including hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breath), and dependence on supplemental oxygen.
A review of Resident 62's Minimum Data Set (MDS - an assessment and care screening tool), dated 9/8/2023, indicated Resident 62 was cognitively intact (able to understand and make decisions).
A review of Resident 62's Self-Administration of Medication, dated 9/15/2023, indicated Resident 62 did not meet the criteria of self-administration of medication and the license nurse will continue to administer medication as ordered and monitor for adverse side effects.
During a concurrent observation and interview with Resident 62 on 10/2/2023, at 9:33 AM, inside Resident 62's room, medication cups containing medications were observed on Resident 62's bedside table. Resident 62 stated he requested for his medications to be left at the bedside table. Resident 62 stated he would take his medications when he gets out of bed. Resident 62 further stated the medications he is receiving includes aspirin (a medication used to treat aches and pain or to thin the blood), pain and blood pressure blood pressure medication.
During a concurrent interview and record review with the Infection Preventionist (IP) on 10/5/2023, at 3:40 PM, Resident 62's Self-Administration of Medication, dated 9/15/2023, was reviewed and the IP stated it indicated Resident 62 does not meet the criteria of self-administration of medication. The IP stated it is not appropriate to leave medications at the bedside because residents would not be able to determine if they are having adverse reactions and to prevent residents from taking too much medication.
During an interview with the Director of Nursing (DON) on 10/6/2023, at 5:33 PM, the DON stated it is not appropriate to leave medications at the bedside, unless the resident was cleared for medication self-administration. The DON further stated it is important to not leave medications at the bedside to ensure residents take their medication and not throw away their medications.
A review of the facility's policy and procedure titled, Self-Administration of Medications, reviewed 5/2023, indicated residents have the right to self-administer medications if the interdisciplinary team (IDT - a group of health care professionals with carious areas of expertise who work together towards the goals of the resident) has determined that it is clinically appropriate and safe for the resident to do so. The policy indicated the following:
1. The IDT considers the following when determining whether self-administration of medications is safe and appropriate for the resident:
a. Medication is safe for self-administration.
b. Able tread and understand medication labels.
c. The resident can follow directions and tell time when to know when to take the medication.
d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report to staff.
e. The resident is safely and securely store the medication.
2. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status.
3. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.
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 the resident's clinical records were updated regarding advan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's clinical records were updated regarding advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them) for one of eight sampled residents (Resident 227) when Resident 227's Advance Directive Acknowledgement form was left blank.
This deficient practice had the potential to cause conflict with a resident's wishes regarding their care.
Findings:
A review of Resident 227's admission Record indicated Resident 227 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, generalized muscle weakness, history of falling and deaf (lacking the power of hearing or having impaired hearing).
A review of Resident 227's Minimum Data Set (MDS - an assessment and care screening tool), dated 9/29/2023, indicated Resident 227 was cognitively intact (able to understand and make decisions) and had moderate difficulty hearing.
During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on 10/3/2023, at 9:10 a.m., Resident 227's medical record was reviewed and indicated the Advance Directive Acknowledgement form, undated, was not signed. LVN 1 confirmed Resident 227's Advance Directive Acknowledgement form was not signed and stated it is important for the resident to have signed the form so that the resident can make an informed about what they would want to happen in the event of a medical emergency.
During an interview with the Director of Social Services (DSS), on 10/4/2023, at 9:24 a.m., the DSS stated Resident 227 did not sign the Advance Directive Acknowledgement form. The DSS stated if the resident does not sign it, the DSS does not sign it. The DSS stated on the Social Services Assessment, conducted on 9/26/2023, the assessment indicated that Resident 227 did not sign the form.
A review of Resident 227's Social Services Assessment, dated 9/26/2023, indicated Resident 227 was asked if Resident 227 had previously executed an advance directive or power of attorney (a legal document that allows someone else to act on their behalf) and Resident 227 responded no. The assessment indicated the DSS informed Resident 227 should she wish to execute an advance directive or power of attorney to inform the DSS. The assessment further indicated Resident 227 had no desire or interest to execute an advance directive or power of attorney at that time.
During a concurrent interview and record review with the DSS, on 10/4/2023, at 2:25 p.m., Resident 227's Social Services Assessment, dated 9/26/2023, was reviewed and indicated Resident 227 had no desire or interest to execute an advance directive. The DSS stated she did not indicate clearly in the form that Resident 227 did not want to sign the paperwork. The DSS stated a practice performed at the facility is that a note indicating the resident refused to sign is written on the side of where the resident refused to sign and is signed by the witness. The DSS further stated Resident 227's Advance Directive Acknowledgement form does not indicate the resident refused to sign and was signed by the DSS or witness.
During an interview with the Director of Nursing (DON), on 10/6/2023, at 5:33 p.m., the DON stated it is important for residents to sign the Advance Directive Acknowledgement form to respect the wishes of the resident on how their care will be if they no longer have the capacity to understand and make decisions.
A review of the facility's policy and procedure (P&P) titled, Advance Directives, reviewed 5/2023, indicated upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The P&P indicated information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse reporting policy and procedure (P&P) by failing...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse reporting policy and procedure (P&P) by failing to report an allegation of resident-to-resident altercation to the State Survey Agency (Department of Public Health) within two hours for two of eight sampled residents (Resident 67 and Resident 227).
This deficient practice had the potential to result in an unidentified abuse in the facility and had the potential for the residents to experience further abuse.
Findings:
A review of Resident 67's admission Record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait (manner of walking) and mobility, generalized muscle weakness, and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).
A review of Resident 67's History and Physical (H&P), dated 7/24/2023, indicated Resident 67 can make her needs known but cannot make medical decisions.
A review of Resident 67's Minimum Data Set (MDS - an assessment and care screening tool), dated 7/28/2023, indicated Resident 67 had severely impaired cognition (difficulty understanding and making decisions).
A review of Resident 227's admission Record indicated Resident 227 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, generalized muscle weakness, history of falling and deaf (lacking the power of hearing or having impaired hearing).
A review of Resident 227's H&P, dated 9/27/2023, indicated Resident 227 has the capacity to understand and make decisions and has a medical history of deafness.
A review of Resident 227's MDS, dated [DATE], indicated Resident 227 was cognitively intact (able to understand and make decisions) and has moderate difficulty hearing.
A review of Resident 227's Change in Condition, dated 9/26/2023, at 9:00 p.m., indicated Resident 227 claimed Resident 67 hit Resident 227 on the left arm. The change in condition indicated Resident 227's primary clinician was notified on 9/27/2023, at 10:00 a.m.
A review of a facsimile report of suspected dependent adult/elder abuse indicated the facility reported to the state agency a suspected abuse between Resident 67 and Resident 227 on 9/27/2023, at 11:20 a.m.
During an interview with the Director of Social Services (DSS), on 10/6/2023, at 1:26 p.m., the DSS stated the incident of alleged abuse between Resident 67 and Resident 227 occurred on 9/26/2023, at 9:00 p.m. The DSS stated she was notified of the incident on 9/27/2023, at 10:30 a.m. The DSS further stated any suspicions of abuse are reported immediately or within two hours for the safety of the residents and to make sure the residents are doing well and are not in distress.
During an interview with the Director of Nursing (DON), on 10/6/2023, at 2:36 p.m., the DON stated the allegation of abuse between Resident 67 and Resident 227 occurred on 9/26/2023, at around 9:30 p.m. The DON stated she learned of the incident on 9/27/2023 and the report was sent to the state agency on 9/27/2023 by the DSS. The DON stated allegations of abuse should be reported within two hours of learning of the allegation. The DON stated the facility department heads were not notified of the allegation until 9/27/2023. The DON stated it is important to report allegations of abuse within two hours of learning of the allegation for the safety of the residents and so that the facility can initiate the necessary interventions for the residents.
During an interview with the Administrator (ADM), on 10/6/2023, at 3:18 p.m., the ADM stated the allegation of abuse between Resident 67 and Resident 227 occurred on 9/26/2023, at 9:00 p.m. but was reported to the DON on 9/27/2023. The ADM stated the report of suspected dependent adult/elder abuse was sent to the state agency on 9/27/2023, around 11:20 a.m. The ADM stated the reporting was performed within a 24-hour period, but it should be reported within the two-hour window. The ADM stated allegations of abuse should be reported to thoroughly investigate the allegations of abuse, to understand the root cause of the allegations, to ensure staff are providing the right care, and for the safety of the residents.
A review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, reviewed 5/2023, indicated if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to the other officials according to state law. The P&P indicated the administrator or the individual making the allegation immediately reports his or her suspicion to the state licensing/certification agency responsible for surveying/licensing the facility. The P&P further indicated Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury.
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** b. A review of Resident 125's admission Record indicated the facility admitted the resident on 8/15/2023 with diagnoses includin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 125's admission Record indicated the facility admitted the resident on 8/15/2023 with diagnoses including cellulitis (a bacterial skin infection that causes pain, redness, and swelling at the site of infection) of left lower limb, end stage renal disease (a condition that occurs when the kidneys are no longer able to carry out their daily functions, requiring either dialysis [(process of removing waste products and excess fluid from the body] or transplantation [transfer of an organ or tissue form one person to another] to sustain life, and generalized muscle weakness.
A review of Resident 125's History and Physical dated 8/15/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 125's Discharge Summary with a discharge date of 8/28/2023, indicated the resident went to dialysis and decided to go home AMA.
A review of Resident 125's MDS Discharge Assessment (a required assessment when the resident is discharged from the facility) dated 8/28/2023 indicated the resident was discharged to acute hospital.
During a concurrent interview and record review on 10/6/2023 at 2:24 p.m., Resident 125's MDS Discharge Assessment was reviewed with the MDS Director (MDSD). The MDSD stated the resident was discharged AMA. The MDSD stated the MDS Discharge assessment dated [DATE] indicated the resident was discharged to acute hospital. The MDSD stated the MDS assessment coding for Resident 125 was inaccurate and a modified MDS Discharge Assessment has been submitted.
A review of the facility's policy and procedure titled Resident Assessments, last reviewed on 5/2023, indicated the Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) conducts timely and appropriate resident assessments and reviews according to the requirements.
Based on observation, record review, and interview the facility failed to ensure Minimum Data Set (MDS-a resident assessment and care screening tool) assessments accurately reflect the resident's status for three of four sampled residents (Residents 101, 60, and 125) by:
1. Failing to ensure the assessment did not indicate Resident 101 was receiving anticoagulant medication.
This deficient practice had the potential to cause errors in medical treatment and care planning for the resident.
2. Failing to ensure the assessment did not indicate Resident 125 was discharged to acute hospital.
This deficient practice had the potential to negatively affect Resident 125's plan of care and delivery of necessary care and services upon discharge.
Findings:
a. A review of Resident 101's admission Record indicated the facility admitted the resident on 7/16/2023 with diagnoses including acute (sudden) osteomyelitis (a condition where there is inflammation and swelling in a bone), left ankle and foot and type II diabetes mellitus (a disease when the body does not produce enough insulin [blood sugar] to function properly, or the body's cells don't react to insulin).
A review of Resident 101's History and Physical, dated 9/22/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 101's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/1/2023, indicated the resident was cognitively intact. The MDS indicated the resident required limited assistance with bed mobility, transfer, walk in room and in corridor, locomotion on and off unit, toilet use, and personal hygiene with one-person physical assist. The MDS indicated the resident received anticoagulant (blood thinner medications) in the last seven days.
During a concurrent interview and record review of Resident 101's physician orders, with the MDS Coordinator (MDSC) stated the resident did not have orders for anticoagulant medications.
During a concurrent interview and record review of Resident 101's MDS Assessment, dated 9/1/2023, with the MDSC, the MDSC stated Section N under anticoagulant was not accurately coded. The MDSC stated the resident was not taking any anticoagulant medications.
During an interview on 10/6/2023 at 2:29 p.m., the MDSC stated the MDS Assessments should be completed in accordance with the Resident Assessment Instrument (RAI, helps nursing home staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) manual. The MDSC stated the RAI Assessment policy indicated that the person who signs the sections should ensure that the information entered should be accurate. The MDSC stated she is responsible in verifying the completion of the assessments.
A review of the facility's policy and procedure titled, Resident Assessments, approved on 5/2023, indicated that all persons who have completed any portion of the MDS Resident Assessment Form must sign the document testing the to the accuracy of such information.
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 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 eight sampled residents (Resident 88).
This deficient practice had the potential for not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility.
Findings:
A review of Resident 88's admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and 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 88's Minimum Data Set (MDS - an assessment and care screening tool), dated 9/19/2023, indicated Resident 88 was cognitively intact (able to understand and make decisions) and had diagnoses including anxiety disorder, depression, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
A review of Resident 88's Order Summary Report indicated Resident 88 was ordered the following medications on 9/13/2023:
-
Duloxetine (medication used to treat depression and anxiety) 60 milligrams (mg - unit of measure) one capsule by mouth two times a day for depression manifested by facial sadness.
-
Quetiapine (medication used to treat schizophrenia, bipolar disorder, and depression) 200 mg one tablet by mouth one time a day for bipolar disorder manifested by calm to hostile behavior.
-
Quetiapine 50 mg one tablet by mouth in the evening for bipolar disorder manifested by calm to hostile behavior.
-
Trazadone (medication used to treat depression) 150 mg one tablet by mouth in the evening for depression manifested by inability to sleep.
During a concurrent interview and record review, on 10/3/2023, at 12:00 p.m., with the MDS Nurse (MDSN) 1, Resident 88's medical record was reviewed and indicated there was no Preadmission Screening and Resident Review (PASARR). MDSN 1 confirmed Resident 88 did not have PASARR in her medical record and stated she will check with the admissions department if it was submitted from the general acute care hospital (GACH).
During an interview with MDSN 1, on 10/4/2023, at 9:00 a.m., MDSN 1 stated the GACH was unable to perform the PASARR screening for Resident 88. MDSN 1 provided a letter addressed to Resident 88 that indicated, on 10/3/2023, Resident 88 had a positive level I screening and a level II mental health evaluation was required.
During an interview with Resident 88, on 10/4/2023, at 10:06 a.m., Resident 88 stated she has anxiety and sometimes depression and she takes medications to help treat her mood.
During an interview with MDSN 1, on 10/5/2023, at 2:55 p.m., MDSN 1 stated if the GACH is unable to perform the PASARR, the facility requests for it to be done. MDSN 1 stated Resident 88 was admitted to the facility on [DATE] and the PASARR was requested on 10/3/2023. MDSN 1 stated the timeframe for request for PASARR is on the same day of admission or the day after admission. MDSN 1 stated Resident 88's PASARR was overlooked. MDSN 1 stated the important of the PASARR is to screen for behavior to determine if skilled nursing is an appropriate setting for the resident. MDSN 1 stated if the PASARR is not performed timely, the facility would not be able to determine if a skilled nursing facility is an appropriate setting for the resident and if the resident needed to be on a psychiatric unit, the facility would not know.
During an interview with the Admissions Coordinator (AC), on 10/5/2023, at 3:37 p.m., the AC stated the PASARR is one of the requirements prior to admission from the GACH and if the GACH was not able to do the screening, the screening will be endorsed to the nursing staff in the facility. The AC stated the timeframe for PASARR request should either be the same day or the next day of admission. The AC stated every resident that is admitted gets a PASARR screening. The AC further stated it is important to perform the PASARR to determine if a skilled nursing facility is an appropriate setting for the resident.
During an interview with the Director of Nursing (DON), on 10/6/2023, at 5:33 p.m., the DON stated the PASARR should be conducted within 24 hours of admission. The DON stated the importance of performing the PASARR is to determine if skilled nursing facilities are an appropriate care setting for the resident.
A review of the facility's policy and procedure (P&P) titled, PASRR (Patient Assessment and Resident Review) Completion Policy, reviewed 5/2023, indicated the center will make sure that all admissions have the appropriate PASRR completed. The P&P indicated the center administrator will designate either the admissions director or social worker to make sure that the PASRR and/or Level of Care is done on all potential residents. The P&P indicated if the referral indicates anything which might constitute a serious mental illness (SMI - diagnosis including, but not limited to bipolar disorder, major depression, and anxiety disorders) or intellectual disability (condition that limits intelligence and disrupts abilities necessary for living independently) the PASRR must be completed prior to admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan (initial written guide that organizes ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) within 48 hours of admission for one out of seven sampled residents (Resident 281) investigated under care planning care area.
This deficient practice had the potential for the resident not to receive appropriate care and treatment specific to his needs.
Findings:
A review of Resident 281's admission Record indicated the facility admitted the resident on 9/24/2023 and readmitted on [DATE] with diagnoses including congestive heart failure (CHF - a condition that develops when your heart does not pump enough blood for your body's needs), pneumonia (an infection of the lungs), and generalized muscle weakness.
A review of Resident 281's History and Physical dated 9/25/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 281's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/5/2023, indicated the resident had an intact cognition ((mental action or process of acquiring knowledge and understanding) and required set up assistance from staff with eating, and oral hygiene, substantial assistance with personal hygiene, and dependent to staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a concurrent interview and record review on 10/4/2023 at 10:42 a.m., Resident 281's care plan was reviewed with the MDS Coordinator (MDSC). The MDSC stated that the baseline care plan (initial written guide that organizes information about the resident's care) was not developed. The MDSC stated the baseline care plan should have been developed within 48 hours of admission for all members of the team to be aware of the resident's plan of care to properly provide care and intervention for the resident.
A review of the facility's policy and procedure titled, Care Plan-Baseline, last reviewed on 5/2023, indicated a policy statement that a baseline plan of care to meet the resident's immediate needs shall be developed for each resident with forty-eight (48) hours of admission. 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)
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** b. A review of Resident 55's Record of admission indicated that the facility admitted Resident 55 on 8/1/2022 and readmitted the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 55's Record of admission indicated that the facility admitted Resident 55 on 8/1/2022 and readmitted the resident on 8/19/2023 with diagnoses including metabolic encephalopathy (damage or disease that affects the brain), abnormalities in gait and mobility (problem with walking), and muscle weakness (lack of muscle strength).
A review of Resident 55's Physical and History, dated 8/19/2023, indicated Resident 55 did not have the capacity to understand and make decisions.
A review of Resident 55's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/8/2023, indicated that Resident 55 could not walk and required one-persons assistance (staff provide weight-bearing support when the resident is involved in an activity) with bed mobility, dressing, toileting, personal hygiene and eating.
A review of Resident 55's Physician Order, dated 8/19/2023, indicated to discontinue the order for the floor mat next to the bed.
A review of Resident 55's Care Plan, dated 8/30/2022, indicated that the resident is at risk for fall and a floor mat should be next to the bed as a landing pad per MD order.
During a concurrent interview and record review on 10/6/2023 at 2:40 p.m., Resident 55's medical record was reviewed with QA (Quality Assurance RN). The QA verified that Resident 55's care plan indicated that a floor mat should be next to the bed, and the current order indicated that the floor mat was discontinued. The QA stated that the licensed nurses were responsible for updating the care plan to reflect the change in Resident 55's fall risk assessment upon readmission on [DATE].
A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, last reviewed on 5/2023, indicated that the assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.
Based on observation, interview and record review the facility failed to ensure the interdisciplinary team (IDT) review and revise the resident's care plan for two (Resident 55 and Resident 282) of two residents by:
1. Failing to indicate in the care plan an order by the physician to change the resident's peripherally inserted central catheter (PICC - a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) to a midline catheter (vascular access device placed into a peripheral vein) for Resident 282.
2. Failing to update the resident's care plan to reflect changes in the fall risk assessment for Resident 55 after readmission on [DATE].
These deficient practices placed the residents at risk for inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.
Findings:
a. A review of Resident 282's admission Record indicated the facility admitted the resident on 9/18/2023 and readmitted the resident on 10/1/2023 with diagnoses including osteomyelitis (inflammation or swelling that occurs in the bone), epilepsy (a condition that affects the brain and causes frequent seizures), and generalized muscle weakness.
A review of Resident 282's History and Physical dated 9/19/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 282's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/25/2023, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision from staff with eating, limited assistance with bed mobility, and extensive assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 282's Order Summary Report indicated the following orders dated 9/23/2023:
1.
Discontinue the PICC line, resident pulled out accidentally.
2.
May insert midline either as stat (right away) or routine.
A review of Resident 282's care plan on antibiotic therapy related to sternal (also known as breastbone) osteomyelitis until completion initiated on 9/18/2023 with target date of 12/30/2023, indicated to monitor PICC line site every shift for any signs and symptoms of infection, swelling, pain, redness, and untoward complications.
During a concurrent observation and interview on 10/3/2023 at 8:46 a.m., Resident 282 was observed with a venous catheter on the right upper arm dated 10/2/2023. The Assistant Director of Nursing stated that the resident had a midline catheter for intravenous antibiotics (medications that are administered directly into a vein so that the medicine can enter the bloodstream immediately).
During a concurrent interview and record review on 10/3/2023 at 3:00 p.m., Resident 282's medical record was reviewed with Minimum Data Set Coordinator (MDSC). The MDSC verified that Resident 282's care plan indicated PICC line, and the current order indicated the resident was on a midline catheter. The MDSC state the licensed nurses are responsible to update the care plans reflecting the change in the type of venous catheter. The MDSC stated the care plan should have been updated to reflect the use of midline catheter so that the members of the team to be aware of the current plan of care necessary to deliver care and services the resident needed.
A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed 5/2023, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were provided a communication device...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were provided a communication device to allow communication between staff and residents for one of eight sampled residents (Resident 227), when Resident 227 was not provided a dry erase marker for the white board that the resident uses to communicate with staff and visitors.
This deficient practice had the potential to delay Resident 227's care and communication with staff and visitors.
Findings:
A review of Resident 227's admission Record indicated Resident 227 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, generalized muscle weakness, history of falling and deaf (lacking the power of hearing or having impaired hearing).
A review of Resident 227's Minimum Data Set (MDS - an assessment and care screening tool), dated 9/29/2023, indicated Resident 227 was cognitively intact (able to understand and make decisions) and has moderate difficulty hearing.
A review of Resident 227's Social Services Assessment, dated 9/26/2023, indicated Resident 227's strengths included being able to make needs known to staff with a white board or by pen and paper.
A review of Resident 227's Care Plan, dated 9/28/2023, indicated Resident 227 has a communication problem related to hearing deficit, deafness, and the resident prefers to speak English. Resident 227's care plan indicated a goal that included Resident 227 will be able to make basic needs known by writing on a white board with a dry erase on a daily basis. Resident 227's care plan interventions included monitoring the effectiveness of communication strategies and assistive devise and Resident 227 preferred to use dry erase and white board, provide at the bedside.
During a concurrent observation and interview with Resident 227, on 10/2/2023, at 1:44 p.m., inside Resident 227's room, Resident 227 was observed in bed with a white board on the bedside table. Resident 227 stated she is deaf and uses a writing board to communicate. Resident 227 stated she needed a marker. Further observation indicated there was no dry erase marker present at the bedside.
During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1, on 10/2/2023, at 1:58 p.m., inside Resident 227's room, Resident 227 did not have dry erase markers at the bedside. LVN 1 stated Resident 227 is deaf and communicates with a white board and dry erase markers. LVN 1 stated if Resident 227 does not have markers, she might become angry or yell for help. LVN 1 further stated without the dry erase markers, it is more difficult to communicate with Resident 227.
During an interview with the Director of Nursing (DON), on 10/6/2023, at 5:33 p.m., the DON stated it is important for residents to have tools for communication for them to clearly communicate their needs to the staff.
A review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, reviewed 5/2023, indicated to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the resident in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. The P&P indicated staff will interact with the residents in a way that accommodates the physical or sensory limitations of the resident, promotes communication, and maintains dignity. The P&P further indicated staff will help keep hearing aids, glasses, and other adaptive devices clean and in working order for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one (Resident 27) of one sampled resident investigated under the activities of daily living (ADL- basic tasks that mus...
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Based on observation, interview, and record review, the facility failed to ensure one (Resident 27) of one sampled resident investigated under the activities of daily living (ADL- basic tasks that must be accomplished every day for an individual to thrive) was provided care and services to maintain good grooming and personal hygiene.
This deficient practice resulted in Resident 27 having poor grooming and personal hygiene. This had the potential to have a negative impact on the resident`s quality of life and self-esteem.
Findings:
A review of Resident 27's admission Record indicated the facility admitted the resident on 5/30/2014 and readmitted the resident on 6/14/2023 with diagnoses including heart failure (a condition in which the heart cannot pump blood well enough to meet the body's needs), dysphagia (difficulty swallowing), and gastrostomy (G-tube - a surgical procedure for inserting a tube through the abdomen wall and into the stomach and used for feeding or drainage).
A review of Resident 27's History and Physical dated 6/15/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 27's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/21/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required extensive assistance from staff bed mobility, and toilet use, and dependent to staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of resident 27's care plan indicated the following:
1.
ADL self-care performance deficit initiated 3/29/2019, last revised 9/29/2019, and target date 1/2/2024 indicated the following interventions:
a.
The resident requires extensive assistance by one staff with personal hygiene and oral care.
b.
The resident requires extensive to total assistance with one staff with showering on shower days and sponge bath as necessary.
2.
Bowel/bladder incontinence related to impaired cognitive function, requires assistance with toileting needs, ADLs and functional limitation. At risk for urinary tract infection (UTI - urine infection) and skin breakdown initiated 7/19/2018, last revised 9/24/2019 indicated the following interventions:
a.
Clean after each episode of incontinence.
b.
Keep clean and dry.
c.
Provide peri care after each incontinent episode.
During an observation on 10/3/2023 at 8:34 a.m., observed Resident 27 lying in bed and smelling urine.
During a concurrent observation and interview on 10/3/2023 at 9:25 a.m., Certified Nursing Assistant 6 (CNA 6) stated that Resident 27 smelled of urine and her incontinence briefs needed to be changed. CNA 6 stated she has not changed the resident's incontinence briefs since the shift has started. CNA 6 stated it is important to change the resident's briefs timely to prevent skin breakdown.
During a concurrent observation and interview on 10/3/2023 at 9:33 a.m., Certified Nursing Assistant 12 (CNA 12) verified that Resident 27 smelled of urine and needed to be changed. CNA 12 verified that Resident 27's incontinence brief and sheets were soaking wet with urine. CNA 12 stated it was important to change the residents timely to prevent infection and skin breakdown.
During an interview on 10/4/2023 at 10:00 a.m., the Quality assurance (QA) nurse verified the presence of bowel and bladder incontinence care plan for Resident 27 that indicate the residents should be provided good incontinence care to maintain good personal hygiene and kept clean and dry to prevent risk for UTI and skin breakdown. The QA nurse stated the Certified Nursing Assistants (CNAs) were supposed to check on the residents at the beginning of their shifts and provide incontinence care if needed. The QA nurse stated Resident 27 should have been provided incontinence care timely. The QA nurse stated it was a dignity issue and placed the resident at risk for skin breakdown and UTI.
A review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, last reviewed 5/2023, indicated that residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care including support and assistance with hygiene (bathing, dressing, grooming, and oral care).
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 interview and record review the facility failed to provide the necessary treatment and services consistent with profess...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the necessary treatment and services consistent with professional standards of practice to two out of three sampled residents (Residents 102 and 117) by failing to consistently assess and document the pressure injuries (also known as pressure injuries, the breakdown of skin integrity due to pressure) of Residents 102 and 107.
The deficient practice had the potential for infection, delayed healing of the pressure injuries and development of new pressure ulcer to residents.
Findings:
A review of Resident 102's admission Record indicated the facility admitted Resident 102 on 11/29/2022 and readmitted the resident on 4/11/2023, with diagnoses including unstageable (when the stage is not clear) pressure ulcer on the right heel, unstageable pressure ulcer on the left heel, and deep tissue damage (when there is no open wound, but the tissues beneath the surface have been damaged) of the sacral region (located below the lumbar spine and above the tailbone).
A review of Resident 102's History and Physical (H&P), dated 4/12/2023, indicated Resident 102 had the capacity to understand and make decisions.
A review of Resident 102's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/26/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 102 needed extensive assistance on bed mobility, dressing, toilet use, and hygiene with one to two-persons assistance. The MDS indicated Resident 102 was always incontinent of bowel (feces). The MDS indicated Resident 102 was on pressure reducing device for bed and chair, nutrition or hydration intervention, and pressure ulcer/injury care.
A review of Resident 102's Braden Scale for Predicting Pressure Sore Risk (a standardized assessment tool commonly used in healthcare to assess and document a patient's risk for developing pressure injuries), dated 7/26/2023, indicated the resident had moderate risk for developing a pressure injury.
A review of Resident 102's Order Summary Report indicated the following order:
-Right heel pressure injury stage 3 (full thickness tissue loss): cleanse with normal saline (NS, a sterile solution to was wounds) pat dry, apply betadine solution (antibacterial agent), leave open to air (LOA) daily (qd) for 30 days. Re-eval 10/25/2023 every day shift for 30 days on 9/22/2023.
A review of Resident 102's Weekly Pressure Ulcer Record dated 7/2023 to 10/2023 indicated missing documentation of weekly assessments for the following dates:
7/16/2023 to 7/22/2023
7/23/2023 to 7/29/2023
7/30/2023 to 8/5/2023
8/6/2023 to 8/12/2023
8/20/2023 to 8/26/2023
8/27/2023 to 9/2/2023
A review of Resident 102's Treatment Administration Record (TAR, a record where licensed nurses document their treatment) from 7/2023 to 10/2023 indicated missing documentation of assessment and treatment of the pressure ulcers on 9/10/2023, right heel pressure injury stage 3: cleanse with NS, pat dry, apply betadine solution, LOA qd for 30 days. Re-eval 10/25/2023 every day shift for 30 days.
A review of Resident 102's Care Plan, last revised on 8/18/2023, indicated Resident 102 had potential/actual impairment to skin integrity of the right heel due to (d/t) stage 3 pressure injury (PI) with an intervention to change the dressing daily.
A review Resident 117's admission Record indicated the facility admitted Resident 117 on 8/10/2023, with diagnoses including pressure ulcer of left buttock stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle), pressure ulcer of sacral region unstageable, and non-pressure (not related to pressure) chronic ulcer of back.
A review of Resident 117's MDS, dated [DATE], indicated Resident 117 had the ability to make self-understood and understand others. The MDS indicated Resident 117 needed extensive assistance on bed mobility, transfer, dressing, toilet use, and personal hygiene with one to two persons assistance. The MDS indicated Resident 117 was incontinent of bowel (feces). The MDS indicated Resident 117 was on pressure reducing device for bed and pressure ulcer/injury care.
A review of Resident 117's Order Summary Report indicated the following order:
-Left Buttock PI Stage 4: cleanse with NS, pat dry, apply Santyl ointment (a Food and Drug Administration [FDA]-approved prescription medicine that removes dead tissue from wounds so they can start to heal) and collagen (a type of moisture dressing), barrier cream to peri wound (tissue surrounding a wound), cover with dry dressing (DD) and if necessary (PRN) for 30 days. Re-eval 10/27/2023 as needed for left buttock on 10/2/2023.
A review of Resident 117's Braden Scale for Predicting Pressure Sore Risk, dated 7/26/2023, indicated Resident 117 was at risk for developing pressure ulcer.
A review of Resident 117's TAR from 7/2023 to 10/2023 indicated missing documentation of assessment and treatment on 9/10/2023, for left Buttock PI Stage 4: cleanse with NS, pat dry, apply Santyl ointment and collagen, barrier cream to peri wound, cover with DD and PRN for 30 days. Re-eval 10/27/2023 as needed for left buttock.
A review of Resident 117's Care Plan, last reviewed on 8/13/2023, indicated Resident 117 had a stage 4 pressure ulcer on the left buttock with an intervention to administer treatments as ordered and monitor for effectiveness.
During a concurrent interview and record review on 10/4/2023, at 9:24 a.m., reviewed Resident 102's medical records with LVN 10. Licensed Vocational Nurse 10 (LVN 10) stated there were missing documentation of weekly assessments of the pressure ulcers from 7/2023 to 9/2023. LVN 10 stated there was a missing entry of a treatment on 9/10/2023 on the right heel Stage 3 on the TAR. LVN 10 stated it was important to complete weekly pressure ulcer assessments in order to know if the wound was getting better.
During a concurrent interview and record review on 10/4/2023, at 9: 50 a.m., reviewed the Resident 117' medical records with LVN 10. LVN 10 stated that on 9/10/2023, the treatment and dressing change was not signed for the order: Left Buttock PI Stage 4: cleanse with NS, pat dry, apply Santyl ointment and collagen, barrier cream to peri wound, cover with DD and PRN for 30 days. Re-eval 10/27/2023 as needed for left buttock. LVN 10 stated it was important to make sure that the TAR was signed by the treatment nurse to indicate that the nursing intervention was done.
During an interview on 10/6/2023, at 10:05 a.m., the Director of Staff Development (DSD) stated the licensed staff needs to assess and document the treatment provided in the TAR in order to determine if the wound was healing or progressing. The DSD stated if the treatment was not documented it was not provided. The DSD stated not providing the treatment had the potential for the development of new pressure injuries or worsening of the pressure injury.
During an interview on 10/6/2023, at 10:28 a.m., the Director of Nursing (DON) stated the treatment and assessment should be documented to show it was done. The DON stated not assessing and providing treatment to the resident's pressure injury had the potential for the pressure injury to worsen.
A review of the facility's recent policy and procedure titled Pressure Injury Risk Assessment, last reviewed on 5/2023, indicated the purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs). Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. Conduct a comprehensive skin assessment with every risk assessment. The following information should be recorded in the resident's medical record utilizing facility forms: 2. The date and time and type of skin care provided, if appropriate. The name and title (or initials) of the individual who conducted the assessment.
A review of the facility's recent policy and procedure titled Charting and Documentation, last reviewed on 5/2023, indicated all services provided to the resident, progress toward the care plans goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
The following information is to be documented in the resident medical record: b. medications administered; c. treatments or services performed; f. progress toward or changes in the care plan goals and objectives.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure for one out one sampled resident (Resident 97) investigated for limited range of motion (ROM - movement of the joints) received the ...
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Based on interview and record review, the facility failed to ensure for one out one sampled resident (Resident 97) investigated for limited range of motion (ROM - movement of the joints) received the appropriate treatment and services to maintain ROM.
This deficient practice placed the resident at risk for decline in mobility and range of motion.
Findings:
A review of Resident 97's admission Record indicated the facility admitted the resident on 8/4/2023 with diagnoses including acute pyelonephritis (occurs as a complication of an ascending urinary tract infection that spreads from the bladder to the kidneys), bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme high manic episodes to low depressive episodes), and muscle weakness (lack of muscle strength).
A review of History and Physical, dated 8/7/2023, indicated that Resident 97 had the capacity to understand and make decisions.
A review of Resident 97's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/11/2023, indicated that Resident 97 had intact cognition and required one-person physical assistance with bed mobility, transfer, dressing, and personal hygiene.
A review of the Physician Order, dated 8/4/2023, indicated for physical therapy (PT) evaluation and treatment.
A review of Resident 97's care plan, dated 8/4/2023, indicated the resident had limited mobility and limited ROM of left upper extremity (LUE) and left lower extremity (LLE) and required PT evaluation and treatment.
During an interview on 10/6/2023 at 10:24 a.m. with Resident 97, the resident stated that he is not receiving restorative nursing services (RNS) at this time.
During an interview on 10/06/23 at 11:00 a.m. with Restorative Nursing Assistant 1 (RNA 1), RNA 1 stated that Resident 97 did not have an order from PT to perform RNS at this time.
During a concurrent interview and record review of Physical Therapy Discharge Summary with the Physical Therapy Assistant (PTA) on 10/6/2023 at 12:37 p.m., the Physical Therapy Discharge Summary indicated physical therapy treatment was provided to Resident 97 from 8/7/2023 to 9/22/203. The PTA stated that the discharge recommendation and RNS evaluation should be completed within 24 hours of discharge from Physical Therapy. The PTA stated that the discharge recommendations and RNS assessment were not completed until 10/6/2023. The PTA stated that Resident 97 did not receive RNS treatment from 9/23/203 to 10/6/2023. The PTA stated not receiving RNS placed Resident 97 at the risk for decline in functional performance and could result in the resident having lower levels of functional skills as well as increased risk for fall.
A review of Facility Policy named Restorative Nursing Services, revised in May 2023, stated residents may be started on a restorative nursing program upon admission, .when discharged from rehabilitative care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible by failing to ensure the floor in for one o...
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Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible by failing to ensure the floor in for one of two (Resident 277) sampled residents reviewed under Accidents care area by failing to ensure the floor in Resident 277's room was kept dry and a wet floor sign placed on the floor to alert the resident that the floor was wet.
This deficient practice placed the resident at risk for falls and serious injuries.
Findings:
A review of Resident 277's admission Record indicated the facility admitted the resident on 9/20/2023 with diagnoses including left rib fracture (broken rib), difficulty in walking, and hemothorax (a collection of blood in the space between the chest wall and the lung [the pleural cavity] from trauma).
A review of Resident 277's History and Physical dated 9/22/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 277's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/25/2023, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision from staff with eating and limited assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a concurrent observation and interview on 10/2/2023 at 10:38 a.m., observed the floor in Resident 277's room with Licensed Vocational Nurse 11 (LVN 11). LVN 11 verified that the floor was wet and stated that there should have been wet floor sign next to the wet floor to alert the resident that the floor was wet. LVN 11 stated Resident 277 is ambulatory and is at risk for falls.
During an interview on 10/2/2023 at 10:40 a.m., Certified Nursing Assistant 15 (CNA 15), who was the assigned CNA, to Resident 277 and the resident's roommate, stated that she had just finished giving a shower to Resident 277's roommate and forgot to place the wet floor sign. CNA 15 stated Resident 277 is ambulatory and the floor being wet and not placing the wet floor sign placed the resident at risk for fall and injury.
During an interview on 10/2/2023 at 10:45 a.m., Resident 277 stated he saw the floor was wet and did not walk through the wet surface to avoid slipping and falling. Resident 277 stated there was no wet floor sign next to the wet area of the floor.
During an interview on 10/5/2023 at 4:15 p.m., the Director of Nursing (DON), stated that the staff should have called the housekeeper to mop the floor and place the wet floor sign next to the wet area of the floor to prevent residents from falling and sustaining injuries.
A review of the facility's policy and procedure titled, Safety and Supervision of Residents, last reviewed 5/2023 indicated the facility strives to make the environment as free from accident hazards as possible. The policy indicated that resident safety and supervision and assistance to prevent accidents are facility-wide policies. The policy indicated that safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, monitoring, and reporting processes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to evaluate and address the needs of residents at risk or already experiencing impaired nutrition for one of eight sampled residents (Resident...
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Based on interview and record review, the facility failed to evaluate and address the needs of residents at risk or already experiencing impaired nutrition for one of eight sampled residents (Resident 118), when Resident 118's plan of care to perform weekly weights were not performed by the facility.
This deficient practice had the potential for additional weight loss and resulted in Resident 118's delay in care to address his weight loss.
Findings:
A review of Resident 118's admission Record indicated the facility admitted Resident 118 to the facility on 7/21/2023 with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (also known as an ischemic stroke - the disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, other abnormalities of gait (manner of walking) and mobility, generalized muscle weakness, and hypertension (high blood pressure).
A review of Resident 118's Minimum Data Set (MDS - an assessment and care screening tool), dated 7/28/2023, indicated Resident 118 was cognitively intact (able to understand and make decisions).
A review of Resident 118's SBAR Communication Form (Situation-Background-Assessment-Recommendation - a written communication tool that helps provide essential, concise information, usually during crucial situations about the resident), dated 9/14/2023, indicated Resident 118's monthly weight noted with weight loss of eight pounds in 30 days and a recommendation from Resident 118's physician for weekly weights.
A review of Resident 118's Order Summary Report, dated 9/15/2023, indicated an order for weekly weights three times for three weeks for weight loss.
A review of Resident 118's Care Plan, initiated 9/14/2023, indicated Resident 118 had unplanned/unexpected weight loss related to acute illness, poor food intake, and weight loss of eight pounds in 30 days. Resident 118's care plans further indicated an intervention for weekly weights.
A review of Resident 118's MAR, dated 9/15/2023 to 10/5/2023, indicated Resident 118's weekly weights order was performed on 9/15/2023. Resident 118's MAR does not indicate the weekly weights were completed in the following weeks after 9/15/2023.
A review of Resident 118's Weight Summary, dated between 7/21/2023 to 10/6/2023, did not indicate weights recorded after 9/6/2023.
During an interview with Resident 118, on 10/4/2023, at 2:58 p.m., Resident 118 stated he has been losing weight in the facility.
During a concurrent interview and record review with the Infection Preventionist (IP), on 10/6/2023, at 8:46 a.m., Resident 118's SBAR Communication Form, dated 9/14/2023, Order Summary Report, dated 9/15/2023, Resident 118's Care Plan, initiated 9/14/2023, and Resident 118's Weights Summary, dated between 7/21/2023 to 10/6/2023, were reviewed. The IP confirmed Resident 118 had weight loss and interventions to check his weight three times for three weeks. The IP stated there were no weights documented in the electronic medical record after 9/14/2023. The IP stated the Restorative Nurse Assistants (RNA) perform the weight checks and the weights are documented in a separate binder.
During an interview with the IP, on 10/6/2023, at 8:53 a.m., the IP stated Resident 118's weights were not in the weight's binder.
During an interview with the IP, on 10/6/2023, at 9:03 a.m., the IP stated it is important to monitor Resident 118's weight to see if the interventions to prevent additional weight loss was effective or not and the facility would not know if Resident 118 was losing additional weight. The IP further stated if Resident 118's weights were not documented in the MAR or in the Weight Summary, it is possible that the weight monitoring was not performed.
During an interview with the DON, on 10/6/2023, at 5:33 p.m., the DON stated it is important to conduct weight monitoring to address right away what can be causing a resident's weight loss and so that the facility can have appropriate interventions for the weight loss.
A review of the facility's policy and procedure (P&P) titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, reviewed 5/2023, indicated the physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting).
A review of the facility's P&P titled, Nutritional Assessment, reviewed 5/2023, indicated individualized care plans shall address, to the extent possible, time frames and parameters for monitoring and reassessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility:
1. Failed to remove Resident 4's expired Albuterol solution (a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility:
1. Failed to remove Resident 4's expired Albuterol solution (a medication used to prevent and treat breathing problems such as asthma) from Medication Cart A. The medication's expiration date was on 9/14/2023.
2. Failed to remove Resident 327's medication, Alendronate Sodium 70 mg tab (a medication used to help strengthen bones) from Medication Cart B. Resident 327 was discharged from the facility on 7/25/2023.
These deficient practices had the potential for placing the residents at risk for receiving expired medications that can cause adverse effects (unwanted symptoms or side effects).
Findings:
a. A review of Resident 4's admission Records indicated the facility admitted Resident 4 on 8/21/2023 and readmitted the resident on 9/7/2023, with diagnoses including acute respiratory failure (a serious condition that makes it difficult to breathe) with hypoxia (a condition where you do not have enough oxygen in the tissues in your body) and dependent on supplemental oxygen (a treatment that provides you with extra oxygen to breathe in). The admission Record indicated the resident was discahrged on 7/27/2023.
A review of Resident 4's History and Physical, dated 7/14/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/14/2023, indicated the resident had the ability to make self-understood and understand others.
A review of Resident 4's Order Summary Report, date 7/5/2023, indicated an order for albuterol sulfate nebulizer solution 0.63 milligrams (mg, a unit of weight)/ 2 milliliters (ml, a unit of volume), 1 application inhale orally via nebulizer (a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) evert 6 hours as needed for shortness of breath.
During a concurrent observation and interview on 10/6/2023, at 12 p.m., observed with the Infection Preventionist (IP), Resident 4's albuterol sulfate nebulizer solution 0.63 milligrams with expiration date of 9/2023 in Medication Cart A. The IP stated the albuterol sulfate nebulizer solution 0.63 milligrams medication was expired and needed to be discarded immediately. The IP stated the deficient practice had the potential to cause adverse effects to residents when given.
A review of the facility's recent policy and procedure titled Storage of Medication, last reviewed on 5/2023, indicated drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
b. A review of Resident 327's admission Records indicated the facility admitted Resident 327 on 10/6/2017 and readmitted the resident on 7/14/2023 with diagnosis that included age-related osteoporosis (bone disease that develops when bone changes and becomes weak) without current pathological fracture (one in which breaks in the bone were caused by an underlying disease).
A review of Resident 327's MDS, dated [DATE], indicated Resident 327 had the ability to make self-understood and understand others.
A review of Resident 327's Order Summary Report, date 7/14/2023, indicated an order for Alendronate Sodium 70 mg tab. Give 1 tablet by mouth every Tuesday for osteoporosis. Take with 6-8 ounces (oz, a unit of mass, wight or volume) of water. Give 30 minutes before breakfast. Do not lie down for at least 30 minutes or until first food.
During a concurrent observation and interview on 10/6/2023, at 12 p.m., observed with the Infection Preventionist (IP) discharged Resident 327's Alendronate Sodium 70 mg tab in Mediation Cart A. The IP stated Resident 327 was discharged on 7/25/2023, and the medication should have been returned to the pharmacy after the resident was discharged . The IP stated not removing the medication of the discharged resident from the medication cart had the potential for the medication to be mixed up with other resident's medications and cause a medication error (dispensing wrong medication).
A review of the facility's recent policy and procedure titled Storage of Medication, last reviewed on 5/2023, indicated drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to monitor adverse side effects (any unexpected or dangerous reaction to a drug) of Lovenox (a type of medication used to prevent...
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Based on observation, interview and record review, the facility failed to monitor adverse side effects (any unexpected or dangerous reaction to a drug) of Lovenox (a type of medication used to prevent blood from clotting) every shift as ordered by the physician for one of two sampled residents (Resident 98).
This deficient practice placed the resident at risk for unidentified or unreported side effects of Lovenox reactions including bleeding easily and bruising.
Findings:
A review of Resident 98's admission Record indicated the facility admitted Resident 98 on 7/31/2023, with diagnoses including heart disease, intertrochanteric fracture of right femur (a type of hip fracture or broken hip), and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it).
A review of Resident 98's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/7/2023, indicated Resident 98 had the ability to make self-understood and understand others. The MDS indicated the resident was on an anticoagulant (medicines that help prevent blood clots).
A review of Resident 98's Order Summary Report indicated an order of:
-Enoxaparin sodium injection solution prefilled syringe 40 milligrams (mg, a unit of mass or weight)/0.4 milliliter (ml, a unit of volume) (Enoxaparin Sodium). Inject 0.4 ml subcutaneously (beneath, or under, all the layers of the skin) one time a day for deep vein thrombosis (DVT, a blood clot in a deep vein of the leg, pelvis, and sometimes arm) prophylaxis (prevention of a specific disease). Rotate site on 8/1/2023.
-Anticoagulant medication- monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting (N&V), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs (v/s, the heart rate, breathing, blood pressure and temperature), shortness of breath (SOB), nose bleeds. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code Other/See nurses Notes and progress note findings every shift on 8/1/2023.
A review of Resident 98's Medication Administration Record (MAR), for 9/2023 indicated missing documentation of monitoring for side effects on the use of an anticoagulant on:
9/25/2023 7 a.m. to 3 p.m. shift
9/30/2025 11 p.m. to 7 a.m. shift
A review of Resident 98's Care Plan, initiated on 8/16/2023, indicated Resident 98 was on an anticoagulant therapy- Enoxaparin Sodium Injection Solution Prefilled Syringe 40 mg/0.4 ml (Enoxaparin Sodium) for DVT prophylaxis. The care plan had an intervention to administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor/document/report if necessary (PRN) adverse reactions (untoward, harmful effects) of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s.
During an interview and record review on 10/4/2023, at 1:08 p.m., with Licensed Vocational Nurse 6 (LVN 6), reviewed Resident 98's Medication Administration Record. LVN 6 stated the MAR indicated missing documentation of monitoring the resident's anticoagulant use on 9/25/2023 7 a.m. to 3 p.m. and 9/30/2023 11 p.m. to 7 a.m. LVN 6 stated the licensed staff should have documented their assessment on the use of anticoagulant medication in the MAR to ensure resident safety.
During an interview on 10/6/2023, at 10:05 a.m., the Director of Staff Development (DSD) stated the licensed nurses should have assessed and documented for the side effects on the use of an anticoagulant (Lovenox) on Resident 98 to make sure that they were giving the appropriate dosage to the resident or if there was a need to change the dosage.
During an interview on 10/6/2023, at 10:28 a.m., the Director of Nursing (DON) stated the licensed nurses should have assessed and documented the monitoring for side effects on the use of an anticoagulant on Resident 98 so that adverse reactions can be reported to the doctor and acted upon. The DON stated it was important to document as proof that a nursing intervention was done. The DON also stated that they do not have a specific policy and procedure on the use of anticoagulants.
A review of the Manufacturer's Guidelines on the use of Enoxaparin Sodium Injection, USP for subcutaneous and intravenous use with initial U.S. approval in 1993, indicated to alternate injection sites between the left and right anterolateral and left and right posterolateral abdominal wall. During therapy monitor complete blood counts including platelets and stool occult blood. Assess for signs and symptoms of bleeding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure a resident who was receiving a psychotropic (any drug capable of affecting mood, emotions, and behavior) medication was...
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Based on observation, interview and record review, the facility failed to ensure a resident who was receiving a psychotropic (any drug capable of affecting mood, emotions, and behavior) medication was adequately monitored for the use of Sertraline HCl (medication to treat depression) as ordered by the physician for one of three sampled residents (Resident 64) by failing to:
1.
Monitor and document the side effects of Sertraline HCl use every shift.
2.
Monitor and document episode of depression m/b poor appetite AEB < 50 meal intake every shift.
This deficient practice placed Resident 64 at risk of receiving unnecessary psychotropic medication without monitoring and evaluating the effectiveness of the medication.
Findings:
A review of Resident 64's admission Record indicated the facility admitted the resident on 11/9/2023 and readmitted the resident on 7/7/2023, with diagnoses including depression, chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and insomnia (a common sleep disorder).
A review of Resident 64's History and Physical (H7P), dated 8/28/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 64's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/15/2023, indicated Resident 64 had the ability to make self-understood and understand others. The MDS indicated Resident 64 was receiving antidepressant and hypnotic (an agent or drug that produces sleep) medications.
A review of Resident 64's Order Summary Report indicated an order of:
-Sertraline HCl oral tablet 50 milligrams (mg, a unit of mass or weight) (Sertraline HCl). Give 1 tablet via gastrostomy tube (g-tube, a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, and medicine) one time a day for major depressive disorder monitor for behavior (m/b) poor meal intake due to current medical condition on 8/11/2023.
-Anti-depressant(s). Monitor side effects: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia (increased heart rate), muscle tremor, agitation, headache, skin rash, weight gain, and tally w/ hashmarks on the Medication Administration Record every (q) shift on 8/11/2023.
-Monitor episode of depression m/b poor appetite as evidenced by (AEB) less than (<) 50 meal intake every shift on 7/7/2023.
A review of Resident 64's Medication Administration Record indicated missing documentation of monitoring on the following:
-Anti-depressant(s). Monitor side effects: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, weight gain, and tally w/ hashmarks on the MAR q shift every shift ordered on 8/11/2023 on the following dates and shifts:
7/2/2023 7 a.m. to 3 p.m.
7/3/2023 3 p.m. to 11 p.m.
7/3/2023 11 p.m. to 7 a.m.
7/4/2023 7 a.m. to 3 p.m.
7/4/2023 3 p.m. to 11 p.m.
7/4/2023 11 p.m. to 7 a.m.
7/5/2023 7 a.m. to 3 p.m.
7/5/2023 3 p.m. to 11 p.m.
7/5/2023 11 p.m. to 7 a.m.
7/6/2023 7 a.m. to 3 p.m.
7/6/2023 3 p.m. to 11 p.m.
7/6/2023 11 p.m. to 7 a.m.
7/7/2023 7 a.m. to 3 p.m.
7/7/2023 3 p.m. to 11 p.m.
8/8/2023 7 a.m. to 3 p.m.
- Monitor episode of depression m/b poor appetite AEB < 50 meal intake every shift ordered on 7/7/2023 on the following dates and shifts:
7/3/2023 3 p.m. to 11 p.m.
7/3/2023 11 p.m. to 7 a.m.
7/4/2023 7 a.m. to 3 p.m.
7/4/2023 3 p.m. to 11 p.m.
7/4/2023 11 p.m. to 7 a.m.
7/5/2023 7 a.m. to 3 p.m.
7/5/2023 3 p.m. to 11 p.m.
7/5/2023 11 p.m. to 7 a.m.
7/6/2023 7 a.m. to 3 p.m.
7/6/2023 3 p.m. to 11 p.m.
7/6/2023 11 p.m. to 7 a.m.
7/7/2023 7 a.m. to 3 p.m.
7/7/2023 3 p.m. to 11 p.m.
A review of Resident 64's Care Plan, initiated on 4/20/2023, indicated Resident 64 uses psychotropic medication (medications that affect the mind, emotions, and behavior) Sertraline HCl oral tablet 50 mg (Sertraline HCl) with an intervention to monitor/document/report if necessary (PRN) any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia (a movement disorder characterized by uncontrollable, abnormal, and repetitive movements of the face, torso, and/or other body parts), extrapyramidal symptoms (EPS, shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person.
During a concurrent interview and record review on 10/6/2023, at 8:30 a.m., with Licensed Vocational Nurse 8 (LVN 8) and Licensed Vocational Nurse 9 (LVN 9) reviewed Resident 64's medical records that indicated there were missing documentation of monitoring for side effects on the use of antidepressant (Sertraline) on multiple days. LVN 9 stated that if the monitoring was not documented, it was not done. LVN 9 stated it was important to document the monitoring of medication use to determine if there were adverse side effects and to evaluate the effectiveness of the medication.
During an interview on 10/6/2023, at 10:05 a.m., the Director of Staff Development (DSD) stated the staff should have documented the monitoring for the side effects on the use of an antidepressant (Sertraline) every shift to make sure the side effects were addressed and were reported to the doctor.
During an interview on 10/6/2023, at 10:28 a.m., the Director of Nursing (DON) stated the staff should have been documenting the monitoring for side effects on the use of antidepressant (Sertraline) as ordered to help in the gradual dose reduction (GDR, the stepwise tapering of a dose to determine symptoms, conditions or risks can be managed by a lower dose) process. The DON stated it is important to document the monitoring in order to know if the medication is working and to address any adverse side effects.
A review of the facility's recent policy and procedure titled Psychotropic Medication Use, last reviewed on 5/2023, indicated Residents, families, and/or the representative are involved in the medication management process. Psychotropic medication management includes:
a.
Indications for use;
b.
Dose (including duplicate therapy);
c.
Duration;
d.
Adequate monitoring for efficacy and adverse consequences; and
e.
Preventing, identifying, and responding to adverse consequences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately by failing to label Resident 86's acetylcysteine (medication that ...
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Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately by failing to label Resident 86's acetylcysteine (medication that helps thin and loosens mucus in the airways due to certain lung diseases) medication with an open date for one of four sampled medication storage refrigerator (Med Ref 1).
This deficient practice had the potential to place the residents at risk for receiving medications that have become ineffective or toxic due to improper storage leading to health complications and negative outcomes.
Findings:
During a concurrent observation and interview on 10/6/2023 at 8:52 a.m., with the Quality Assurance (QA) Nurse, observed Resident 86's acetylcysteine medication vial, opened with no label indicating the open date. The QA Nurse stated it should have been labeled with an open date.
During an interview on 10/6/2023 at 9:24 a.m., the QA nurse stated when the medication vial is opened it should have been labeled with an open date. The QA Nurse stated if the vial is not labeled then it should have been discarded. The QA Nurse stated the reason it has to be labeled with an open date is because the manufacturer indicated to only use it a certain amount of time once opened.
During an interview on 10/6/2023 at 2:08 p.m., the Assistant Director of Nursing (ADON) stated if the medication vial has been opened it should be dated.
A review of the facility policy and procedure titled, Administering Medications, approved on 5/2023, indicated 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 facility's policy and procedure titled, Storage of Medications, approved on 5/2023, indicated that the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The policy indicated that drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide residents with food that is palatable (referr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide residents with food that is palatable (referring to the taste and/or flavor of the food) for one of eight sampled residents (Resident 123) when Resident 123 stated the broccoli served during lunch on 10/4/2023 was overcooked and mushy.
This deficient practice had the potential for residents to not consume their meals.
Findings:
A review of Resident 123's admission Record indicated the facility admitted the resident on 9/11/2023 with diagnoses including endocarditis (an infection of the heart's inner lining, usually involving the heart valves) and generalized muscle weakness.
A review of Resident 123's MDS, dated [DATE], indicated Resident 123 was cognitively intact (able to understand and make decisions).
A review of Resident 123's Order Summary report, dated 9/11/2023, indicated an order for consistent carbohydrate diet (specialized diet that focuses on serving the same amount of carbohydrates [food consisting of or containing a lot of sugars, starch, cellulose, or similar substances that can be broken down to release energy in the human body] every day to keep blood sugar levels stable).
A review of the facility's Menu, dated 10/4/2023, indicated the facility was serving for lunch egg roll, chicken/broccoli stir fry, steamed rice, almond cookies, whole milk, and a beverage.
During a concurrent observation and interview, on 10/4/223, at 12:57 p.m., with the Dietary Supervisor (DS), a lunch meal tray was requested from the facility. Observation of the chicken broccoli stir fry showed that a plastic fork easily pierced through the broccoli. The DS stated the broccoli was overcooked.
During an interview with Resident 123, on 10/4/2023, at 1:25 p.m., Resident 123 stated the broccoli that came with his lunch was mushy and a little overcooked.
During an interview with the Director of Nursing (DON), on 10/6/2023, at 5:33 p.m., the DON stated meals should be palatable because the appearance of food will enhance residents' appetites.
A review of the facility's policy and procedure (P&P) titled, Food and Nutrition, reviewed 5/2023, indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhance 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 care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality for three of four sampled residents (Residents 281, 33, and 116) investigated for dignity by:
1.
Failing to ensure that Resident 281 who had an indwelling urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) had a privacy bag to cover the urinary catheter drainage bag.
2.
Failing to ensure that Resident 33's privacy curtain was fully drawn, was wearing clothing, fully covered with sheets, and incontinence brief not exposed.
3.
Failing to ensure Resident 116 was served her meal tray simultaneously with the other residents in the dining room during lunch.
These deficient practices had the potential to affect the residents' self-worth and self-esteem.
Findings:
a.
A review of Resident 281's admission Record indicated the facility admitted the resident on 9/24/2023 and readmitted on [DATE] with diagnoses including congestive heart failure (CHF - a condition that develops when your heart doesn't pump enough blood for your body's needs), pneumonia (an infection of the lungs), and generalized muscle weakness.
A review of Resident 281's History and Physical dated 9/25/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 281's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/5/2023, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance from staff with eating, and oral hygiene, substantial assistance with personal hygiene, and dependent to staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During an observation on 10/2/2023 at 1:35 p.m., Resident 281 was observed in bed with urinary the indwelling catheter drainage bag hanging on the left side of the bed facing the door without a privacy bag.
During a concurrent observation and interview on 10/2/2023 at 1:40 p.m., Licensed Vocational Nurse 1 (LVN 1) stated that Resident 281's urinary indwelling catheter drainage bag did not have a privacy bag. LVN 1 stated the urinary catheter drainage bag should be covered with a privacy bag for privacy and to promote dignity.
b. A review of Resident 33's admission Record indicated the facility admitted the resident on 1/19/2023 with diagnoses including congestive heart failure (a condition in which the heart cannot pump blood well enough to meet the body's needs), difficulty in walking, generalized muscle weakness, and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
A review of Resident 33's History and Physical dated 1/23/2023, indicated the resident can make needs known but cannot make medical decisions.
A review of Resident 33's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/5/2023, indicated the resident had moderately impaired cognition ((mental action or process of acquiring knowledge and understanding) and required supervision from staff with eating, total assistance with bathing, and extensive assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During an observation on 10/2/2023 at 11:49 a.m., Resident 33 was lying in bed with the privacy curtain partially open. Resident 33 did not have any clothing on, was partially covered with sheets, and incontinence brief was exposed.
During a concurrent observation and interview on 10/2/2023 at 11:51 a.m., the Director of Staff Development 2 (DSD 2) stated that Resident 33's privacy curtain was partially open. DSD 2 verified that the resident did not have any clothing on, was partially covered with sheets, and her incontinence brief exposed. DSD 2 stated that Resident 33 should have been wearing clothes so that her incontinence brief is not exposed. DSD 2 stated the privacy curtain should have been fully drawn for privacy and to maintain her dignity.
During an interview on 10/5/2023 at 2:00 p.m., the Director of Nursing (DON) stated Resident 281's urinary catheter drainage bag should have been covered with a privacy bag. The DON stated that Resident 33's privacy curtain should have been fully drawn for privacy. The DON stated the resident should have been wearing clothes and covered with a sheet so that her incontinence brief was not exposed. The DON stated all residents should be treated with respect and dignity to preserve their self-worth and self-esteem.
A review of the facility's policy and procedure (P&P) titled, Quality of Life-Dignity, last reviewed 5/2023, indicated the following:
1.
Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, felling of self-worth and self-esteem.
2.
Residents are treated with dignity and respect at all times.
3.
Staff promote, maintain, and protect resident privacy, including bodily privacy.
c. A review of Resident 116's admission Record indicated Resident 116 was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, aphasia (a language disorder that affects a person's ability to communicate) following cerebral infarction (also known as an ischemic stroke - disrupted blood flow to the brain due to problems with the blood vessels that supply it), and dysphagia (difficulty or discomfort in swallowing) following cerebral infarction.
A review of Resident 116's MDS, dated [DATE], indicated Resident 116 was cognitively intact (able to understand and make decisions) and required extensive assistance with one-person physical assistance with eating.
During an observation on 10/2/2023, at 12:18 p.m., in the dining room, Resident 116 was observed in her wheelchair with a table in front of her. Resident 116 was observed with no meal tray in front of her. Further observation of the dining room indicated the other residents in the dining room were served their meal trays and had begun eating.
During a concurrent observation and interview with the Quality Assurance Nurse (QA) on 10/2/2023, at 12:25 p.m., in the dining room, Resident 116 was observed sitting next to the table with no meal tray in front of her. The QA stated lunch was served at 12:15 p.m. and Resident 116's meal tray was not in the tray cart. The QA stated the meal trays should have been served to all the residents in the dining room simultaneously. The QA further stated if residents are not served their meal trays at the same time, it can possibly affect the resident's dignity since the resident will be watching the other residents eat.
During an observation on 10/2/2023, at 12:32 p.m., Resident 116's meal tray was delivered to the resident.
During an interview with the DON, on 10/6/2023, at 5:33 p.m., the DON stated residents should be served their meals simultaneously to maintain the dignity of the resident so that they do not feel left out.
A review of the facility's P&P titled, Quality of Life - Dignity, reviewed 5/2023, 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, feeling of self-worth and self-esteem. The P&P further indicated residents are treated with dignity and respect at all times.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A review of Resident 55's admission Record indicated that the facility admitted Resident 55 on 8/1/2022 with diagnoses includ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A review of Resident 55's admission Record indicated that the facility admitted Resident 55 on 8/1/2022 with diagnoses including metabolic encephalopathy (damage or disease that affects the brain), abnormalities in gait and mobility (problem with walking), and muscle weakness (lack of muscle strength).
A review of Resident 55's Physical and History, dated 8/19/2023 indicated that Resident 55 did not have the capacity to understand and make decisions.
A review of Resident 55's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/8/2023, indicated that Resident 55 could not walk and required one-persons assistance (staff provide weight-bearing support when the resident is involved in an activity) with bed mobility, dressing, toileting, personal hygiene, and eating.
A review of Resident 55's care plan, dated 8/30/2022, indicated that Resident 55 is at risk for falls and injury related to confusion, gait and balance problems, and incontinence; and, that Resident 55 is unaware of the safety needs.
On 10/2/2023 at 10:52 a.m., during observation, observed Resident 55 was lying in bed with no call light within the resident's reach.
On 10/2/2023 at 10:55 a.m., during a concurrent observation and interview, with LVN 5 in Resident 5's room, LVN 5 stated that did not see a call lights within reach of the resident. LVN 5 stated that the absence of a call light has the potential to result in the resident not receiving the care timely.
On 10/6/2023 at 10:55 a.m., during a concurrent observation and interview with LVN 11 and CNA 11 in Resident 5's room, LVN 11 stated that there is no call light in the room. CNA 11 stated that Resident 55 had the habit of biting the call light. LVN 11 stated that the nurses are providing frequent checks on Resident 55 to make sure the resident's needs are met.
During an interview on 10/6/2023 at 8:32 a.m., the ADON stated that according to the facility policy, all residents should have a call light. The ADON stated that a possible outcome of not having a call light within reach could be worsening of the resident's condition because they were not getting help on time.
A review of the facility's policy and procedure titled Answering the Call Light, last reviewed 5/2023, indicated that the purpose of the call lights is so the staff can respond to the residents' requests and needs. The policy indicated when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.
C. A review of Resident 63's admission Record indicated the facility admitted Resident 63 on 8/5/2020 and readmitted the resident on 9/20/2022, with diagnoses including traumatic subdural hemorrhage (a kind of intracranial hemorrhage, which is the bleeding in the area between the brain and the skull), muscle weakness and a fall.
A review of Resident 63's History and Physical (H&P), dated 9/6/2023, indicated Resident 63 had the capacity to understand and make decisions.
A review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/22/2023, indicated Resident 63 had the ability to make self-understood and understand others. The MDS indicated the resident required extensive assistance on bed mobility, dressing, toilet use, and personal hygiene and needed one to two-persons assistance.
A review of Resident 63's Fall Risk Assessment, dated 9/22/2023, indicated Resident 63 was high risk for potential falls.
A review of Resident 63's Care Plan, last revised on 8/22/2022, indicated Resident was a high risk for falls. The interventions included to be sure the resident's call light was within reach and encourage the resident to use them for assistance as needed was in effect.
During a concurrent observation and interview on 10/3/2023, at 8:17 a.m., observed with Certified Nursing Assistant 7 (CNA 7) Resident 63's call light cord was looped in the upper right-side rail of the resident's bed. CNA 7 stated the call light should have not been clipped to the pillow next to the resident for easy reach. CNA 7 stated not having the call light within the resident's reach had the potential for the resident to not able to ask for help when needed and could potentially fall.
D. A review of Resident 98's admission Record indicated the facility admitted Resident 98 on 7/31/2023, with diagnoses including history of falling, displaced intertrochanteric fracture (a type of hip fracture or broken hip), and cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it).
A review of Resident 98's MDS, dated [DATE], indicated Resident 98 had the ability to make self-understood and understand others. The MDS indicated Resident 98 required extensive assistance on bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident 93 required total dependence on locomotion on and off the unit and needed one to two-persons assistance.
A review of Resident 98's Care Plan, last revised on 8/14/2023, indicated Resident 98 had an activity of daily living (ADL, activities related to personal care) self-care performance deficit and an intervention to encourage resident to use bell to call for assistance.
During a concurrent observation and interview on 10/2/2023, at 1:08 p.m., observed with Licensed Vocational Nurse 6 (LVN 6) Resident 98 sitting in the wheelchair (WC). The resident's WC was on the right side of the bed and the call light was on the floor on the left side of the bed. LVN 6 stated the call light should be attached to the bed of the resident and clipped on the pillow. CNA 6 stated not having the call light within the resident's easy reach will result in the resident not being able to call for help and they could end up falling.
E. A review of Resident 104's admission Record indicated the facility admitted Resident 104 on 1/30/2023 and the facility readmitted Resident 104 on 8/13/2023, with diagnoses including hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness or the inability to move one side of the body) following cerebral infarction, abnormalities of gait (a manner of walking or moving on foot) and mobility, and repeated falls.
A review of the Resident 104's H&P, dated 3/9/2023, indicated Resident 104 can make needs known but cannot make medical decisions.
A review of Resident 104's MDS, dated [DATE], indicated Resident 104 had the ability to make self-understood and sometimes had the ability to understand others. The MDS indicated the resident required extensive assistance on bed mobility, transfer, locomotion on and off the unit, dressing, toilet use, and personal hygiene and needed one to two-persons assistance.
A review of Resident 104's Fall Risk Assessment, dated 9/3/2023, indicated the resident was high risk for potential falls.
A review of Resident 104's Care Plan, initiated on 8/1/2023, indicated Resident 104 had an actual fall with no injury, no pain, and an intervention to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed was in effect.
During a concurrent observation and interview on 10/2/2023, at 9:49 a.m., observed with CNA 7 Resident 104's call light cord looped on the upper side-rail of the resident's bed and the button dangling below the bed. CNA 7 stated the call light should not be looped because the resident will have a hard time locating the call button and will not be able to call. CNA 7 stated not having the call light within the reach of the resident could cause the resident to fall.
During an interview on 10/6/2023, at 10:05 a.m., the Director of Staff Development (DSD) stated the call light should be always reachable. The DSD stated when making rounds, if observed the call light was tangled, they need to fix it and clip it to the pillow, so it is available for the resident to use. The DSD stated if the resident needs something the resident cannot get help. The DSD stated the resident can also fall if the resident tries to reach for the call light.
During an interview on 10/6/2023, at 10:28 a.m., the Director of Nursing (DON) stated all staff should ensure the call light is within the resident's reach, because the call light is the resident's tool to ask for assistance. The DON stated not having the call light within the resident's reach could result in the delay of care and placed the residents at risk for accidents such as falls.
A review of the facility's recent policy and procedure titled Answering the Call Light, last reviewed on 5/2023, indicated when resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.
Based on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for five out of five sampled residents (Resident 33, 55, 63, 98, and 104).
This deficient practice had the potential to result in the residents not being able to call for facility staff assistance and increase their risk for injury or fall.
Findings:
A. A review of Resident 33's admission Record indicated the facility admitted the resident on 1/19/2023 with diagnoses including congestive heart failure (a condition in which the heart cannot pump blood well enough to meet the body's needs), difficulty in walking, generalized muscle weakness, and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
A review of Resident 33's History and Physical dated 1/23/2023, indicated the resident can make needs known but cannot make medical decisions.
A review of Resident 33's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/5/2023, indicated the resident had moderately impaired cognition ((mental action or process of acquiring knowledge and understanding) and required supervision from staff with eating, total assistance with bathing, and extensive assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 33's care plan on risk for falls related to gait/balance problems, incontinence, and unaware of safety needs initiated 1/31/2023, last revised 4/27/2023 with a target date 10/24/2023 indicated the following interventions:
1.
To be sure the resident's call light is within easy reach and encourage the resident to use it for assistance as needed.
2.
The resident needs a safe environment with a working and reachable light.
During an observation on 10/2/2023 at 11:49 a.m., observed Resident 33's call light on the floor and not within the resident's easy reach.
During a concurrent observation and interview on 10/2/2023 at 11:51 a.m., the Director of Staff Development 2 (DSD 2) verified that Resident 33's call light was on the floor and not within the resident's reach. DSD 2 stated that the call light should be within Resident 33's reach at all times so the resident would be able to call for assistance if needed.
During an interview on 10/5/2023 at 2:00 p.m., the Director of Nursing (DON) stated call lights should always be within resident's easy reach for staff to be able to respond to residents' needs and requests.
A review of the facility's policy and procedure titled, Answering the Call Light, last reviewed 5/2023, indicated a purpose to respond to the resident's requests and needs. The policy indicated when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure residents had the right to receive mail for two of 10 sampled residents (Resident 50 and Resident 81). Resident 50 and Resident 81 s...
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Based on interview and record review, the facility failed to ensure residents had the right to receive mail for two of 10 sampled residents (Resident 50 and Resident 81). Resident 50 and Resident 81 stated they do not receive mail on Saturdays.
This deficient practice violated the residents' right to receive mail on Saturdays and had the potential to negatively affect the resident's psychosocial well-being.
Findings:
During the with Resident Council meeting on 10/3/2023, at 2:09 p.m., Resident 50 and Resident 81 stated they do not receive mail on Saturdays.
During an interview with Receptionist (RECP) 1 on 10/6/2023, at 9:43 a.m., RECP 1 stated mail is not delivered to residents on Saturdays. RECP 1 stated she does not work on the weekends and stated whoever is working as receptionist on the weekend places the incoming mail in a locked drawer at the receptionist drawer. RECP 1 stated when she comes in on Monday, she finds the mail delivered on the weekends in the drawer. RECP 1 stated the weekend receptionist inputs the incoming mail in the Mails and Delivery Log. RECP 1 stated after she checks the log, the mail is given to the business office.
During a concurrent interview and record review with RECP 1, on 10/6/2023, at 9:50 a.m., the Mails and Delivery Log, dated 9/30/2023, was reviewed and indicated the facility received mail on Saturday. The log indicated the mail was endorsed to the Assistant Business Office Manager (ABOM) and was dated 9/30/2023. RECP 1 stated the ABOM picked up the mail received 9/30/2023 on 10/2/2023.
During an interview with the Business Office Manager (BOM), on 10/6/2023, at 10:00 a.m., the BOM stated when mail comes in the weekend, the receptionist will lock the mail in the receptionist desk. The BOM stated on Monday, the ABOM will pick up the mail when they enter the facility and sign off on the receipt of the mail. The BOM stated the mail received on the weekend will be distributed on Monday. The BOM stated mail received on Saturday is not distributed to the residents on Saturday.
During a concurrent interview and record review with the ABOM, on 10/6/2023, at 10:16 a.m., the Mails and Delivery Log, dated 9/30/2023, was reviewed and indicated the ABOM signed for the mail. The ABOM stated on 10/2/2023, she picked up the resident's mail from the receptionist's desk and brought the mail back to the business office to be sorted. The ABOM stated she does not work on the weekends and on Mondays, she picks up the mail from the receptionist desk.
During an interview with the BOM, on 10/6/2023, at 10:43 a.m., the BOM stated mail is not delivered to residents on Saturdays. The BOM stated it is important for residents to receive mail on Saturdays because the residents may be expecting mail on that day, and they may not be getting their mail timely. The BOM stated residents could possibly get upset from not receiving their mail timely.
During an interview with the Administrator (ADM), on 10/6/2023, at 3:55 p.m., the ADM stated mail should be delivered to residents on Saturdays. The ADM stated the business office sorts the mail and the mail is delivered to the residents by the activities department. The ADM stated it is a resident's right to receive mail within 24 hours. The ADM further stated the facility should not infringe on residents getting personal communication from the outside world and residents may have time sensitive mail that may need to be acted on.
A review of the facility's policy and procedure (P&P) titled, Mail and Electronic Communication, reviewed 5/2023, indicated mail and packages will be delivered to the resident within 24 hours of delivery on premises or to the facility's post office box (including Saturday deliveries).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents were provided with a safe, clean,...
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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 residents were provided with a safe, clean, comfortable, and homelike environment for four of four sampled residents (Resident 34, 76, 118, and 27) by:
1. Failing to ensure electrical wire were not exposed on Resident 34's bed remote control.
This deficient practice had the potential to place Resident 34 at risk for accidents such as electrocution.
2. Failing to maintain a clean, pleasant, and neutral-scent environment for Resident 76's who had a sticky bedroom floor with strong foul odor.
This deficient practice had the potential negatively affect the resident's quality of life.
3. Failing to ensure Resident 118's bathroom sink was not loosely attached to the bathroom wall.
This deficient practice had the potential to make residents feel uncomfortable and place residents at higher risk for accidents.
4. Failing to ensure Resident 27's tube feeding pole was free from dried feeding formula.
This deficient practice resulted in resident not having a clean and sanitary tube feeding pole.
Findings:
a. A review of Resident 34's admission Record indicated the facility admitted Resident 34 on 9/10/2013 and readmitted the resident on 10/17/2021, with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and anxiety.
A review of Resident 34's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/5/2023, indicated Resident 34 usually had the ability to make self-understood and understand others.
A review of Resident 34's Care Plan, last revised on 3/26/2023, indicated Resident 34 was a high risk for falls and injury related to decreased safety awareness, dementia. The care plan had an intervention indicating the resident needs a safe environment with even floors free from spills and/or clutter, a working and reachable call light, personal items within reach.
During an observation on 10/2/2023, at 11:04 a.m., observed exposed wires on Resident 34's bed control, which was in close proximity with the water pitcher.
During an interview on 10/4/2023, at 2:32 p.m., Maintenance Staff 1 (MTS 1) stated the exposed wires on the bed control was not safe because it could cause electrocution (the injury of someone by electric shock). MTS 1 stated the housekeeping staff, and the CNAs should notify him if they see exposed wires on bed controls.
During an interview on 10/6/2023, at 10:05 a.m., the Director of Staff Development (DSD) stated the staff should have kept the water pitcher away from the remote control and the remote control should have been replaced to prevent possible injury to the resident.
During an interview on 10/6/2023, at 10:28 a.m., the Director of Nursing (DON) stated the staff should have reported the issue to the maintenance for replacement of the remote bed control. The DON stated Resident 34's bed control with exposed wires had the potential to cause an accident.
A review of the facility's recent policy and procedure titled Homelike Environment, last reviewed on 5/2023, indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.
d. A review of Resident 27's admission Record indicated the facility admitted the resident on 5/30/2014 and readmitted on [DATE] with diagnoses including heart failure (a condition in which the heart cannot pump blood well enough to meet the body's needs), dysphagia (difficulty swallowing), and gastrostomy (G-tube - a surgical procedure for inserting a tube through the abdomen wall and into the stomach and used for feeding or drainage).
A review of Resident 27's History and Physical dated 6/15/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 27's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/21/2023, indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required extensive assistance from staff bed mobility, and toilet use, and dependent to staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 27's Order Summary Report indicated an order date of 8/8/2023 for Enteral Formula (nutritional liquids that are delivered through G-tube) Fibersource (a type of enteral formula) at 55 milliliters per hour (ml/hr - a unit of measurement) for 20 hours 10 provide 1100 ml/1320 kilocalories (kcal - a unit of measurement)/20 hours. Infuse feeding until total volume is infused via pump or until dose formula complete.
During an observation on 10/3/2023 at 8:34 a.m. and 10/4/2023 at 8:00 a.m. the base of the tube feeding pole was observed with yellow colored, dried substance.
During a concurrent observation and interview on 10/5/2023 at 8:50 a.m., Certified Nursing Assistant 10 (CNA 10) stated the floor under the base of the tube feeding pole was wet and there was wet yellow colored substance on top of the base of the pole. CNA 10 rubbed off the sticky, yellow colored substance from the tube feeding pole. CNA 10 and stated it substance looked like feeding formula that dripped to the base of the tube feeding pole. CNA 10 stated that the pole should have been cleaned but was not sure who was responsible in keeping the tube feeding pole clean.
During a concurrent observation and interview on 10/5/2023 at 8:51 a.m., the Assistant Director of Nursing (ADON) verified the floor under the base of the tube feeding pole had wet yellow colored substance on top of the base. The ADON stated the sticky, yellow colored substance looked like a formula that dripped to the base of the tube feeding pole. The ADON stated that the pole should have been cleaned and the housekeeper is responsible for keeping the tube feeding poles clean.
During a concurrent observation and interview on 10/5/2023 at 8:51 a.m., Housekeeping Staff 1 (HSK 1) verified the base of the tube feeding pole had wet yellow colored substance. HSK 1 stated the housekeeping department is responsible for cleaning the tube feeding poles daily.
During an interview on 10/5/2023 at 9:01 a.m., the Housekeeping Supervisor (HKS) stated the housekeeping department was responsible for cleaning the equipment in resident rooms. The HKS stated the tube feeding in Resident 27's room should have been checked daily and cleaned as needed to provide a clean and homelike environment for the resident.
A review of the facility's policy and procedure titled, Homelike Environment indicated residents are provided with a safe, clean, comfortable, and homelike environment. The policy indicated the facility staff and management maximizes the characteristics of the facility that reflects a personalized, homelike setting to include a clean, sanitary, and orderly environment.
c. A review of Resident 118's admission Record indicated Resident 118 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (also known as an ischemic stroke - the disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, other abnormalities of gait (manner of walking) and mobility, generalized muscle weakness, and hypertension (high blood pressure).
A review of Resident 118's Minimum Data Set (MDS - an assessment and care screening tool), dated 7/28/2023, indicated Resident 118 was cognitively intact (able to understand and make decisions).
During an observation of Resident 118's bathroom, on 10/5/2023, at 10:12 a.m., the bathroom sink was loosely attached to the bathroom wall and the caulking (a waterproof filler and sealant used in building work and repairs) appeared cracked.
During an interview with Resident 118, on 10/5/2023, at 10:14 a.m., Resident 118 stated his bathroom sink was loose and he had concerns with it falling off. Resident 118 further stated his bathroom did not feel homelike.
During a concurrent observation and interview with the Maintenance Supervisor (MS), on 10/5/2023, at 10:34 a.m., inside Resident 118's bathroom, the bathroom sink was loosely attached with caulking to the bathroom wall. The MS stated the bathroom sink is loose and could potentially fall and harm residents.
During an interview with the Director of Nursing (DON), on 10/6/2023, at 5:33 p.m., the DON stated if a bathroom sink is loosely attached to the bathroom wall, it could be a potential safety issue for the residents.
A review of the facility's policy and procedure (P&P) titled, Homelike Environment, reviewed 5/2023, indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.
b. A review of Resident 76's admission Record indicated the facility admitted the resident on 1/24/2023 with diagnoses including UTI and retention of urine.
A review of Resident 76's History and Physical, dated 12/20/2022, indicated the resident had the capacity to understand and make decisions.
A review of Resident 76's MDS, dated [DATE], indicated the resident was cognitively intact and required extensive assistance with bed mobility, locomotion on unit, dressing, toilet use, and personal hygiene with one-person physical assist. The MDS indicated the resident required total dependence with transfer with two-persons physical assist.
During a concurrent observation and interview on 10/3/2023 at 11:09 a.m., observed Resident 76's bedroom floor sticky and smelled of strong odor. The resident stated the strong odor is urine because he emptied his urinary bag and it spilled into the floor. The resident stated the floor has not yet been cleaned.
During a concurrent observation and interview on 10/3/23 at 1:13 p.m., observed Resident 76 in bed and the bedroom floor sticky and smelled of strong odor.
During a concurrent observation and interview on 10/3/23 at 2:56 p.m., at Resident 76's bedside, CNA 1 stated the floor is sticky but does not know when housekeeping came and cleaned the room. CNA 1 stated the floor should not be sticky because it is not safe because the residents can trip and fall.
During a concurrent observation and interview on 10/3/23 at 2:59 p.m., at Resident 76's bedside, Housekeeping Staff 1 (HSK 1) stated the last time she cleaned this room was at 1 p.m. HSK 1 stated the floor has urine. Observed HSK 1 mopped the floor and disinfected the floor.
During an interview 10/6/2023 at 2:01 p.m., the Assistant Director of Nursing (ADON) stated the resident's room should be clean, free from clutter, and free from water spill. The ADON stated if the floor is not clean and tidy, it affects the resident because they could fall and hurt themselves. The ADON stated the resident's poor safety awareness cause them to fall and break their bones. The ADON stated the having a room smelling of foul odor is not good for the health of the residents.
A review of the facility's policy and procedure titled, Homelike Environment, approved on 5/2023, indicated the residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The procedure indicated that facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect A personalized home like setting which includes characteristics of clean, sanitary, and orderly environment, pleasant and neutral sense.
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** d. A review of Resident 97's admission Record indicated the facility admitted Resident 97 on 8/4/2023 with diagnoses including a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. A review of Resident 97's admission Record indicated the facility admitted Resident 97 on 8/4/2023 with diagnoses including acute pyelonephritis (occurs as a complication of an ascending urinary tract infection that spreads from the bladder to the kidneys), bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme high manic episodes to low depression episodes), and muscle weakness.
A review of History and Physical, dated 8/7/2023, indicated that Resident 97 had the capacity to understand and make decisions.
A review of Resident 97's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/11/2023, indicated that Resident 97 had intact cognition and required one-person physical assistance with bed mobility, transfer, dressing, and personal hygiene.
A review of the Physician Order, dated 8/4/2023, indicated the following orders:
-Monitor for side effects of antipsychotic medication such as drowsiness, dry mouth, constipation, blurred vision, extrapyramidal reaction (involuntary movements that you cannot control), weight gain, edema (swelling caused by collection of fluid in the body's tissues), postural hypotension (low blood pressure upon standing from a seated or laying position), sweating, loss of appetite, and urinary retention (condition in which you cannot empty all the urine from your bladder) every shift. Another Physician Order, dated -
-Monitor for parkinsonism (tremor, drooling and rigidity) every shift.
A review of Resident 97's care plan, dated 9/5/2023, indicated that the following:
-The resident was receiving Seroquel 200 mg (a unit of measurement), a psychotropic medication, daily.
-Administer psychotropic medication as ordered by the physician and to monitor for side effects and effectiveness every shift.
During a concurrent interview and record review of the MAR (Medication Administration Record) with LVN 2 on 10/5/2023 at 12:25 p.m., LVN 2 stated that there was missing documentation for monitoring for side effects of antipsychotic medication and for parkinsonism on 9/25/2023 during the morning shift from 7 a.m. to 3 p.m. LVN 2 stated that the missing documentation indicated that it was not done. LVN 2 stated that not monitoring for side effects of antipsychotic medication may put Resident 97 at risk for psychotropic drug related complications.
During a concurrent interview and record review of the MAR with LVN 6 on 10/6/2023 at 10:44 a.m., LVN 6 stated that she forgot to document the monitoring for side effects of psychotropic medication on 9/25/2023 for Resident 97. LVN 6 stated that documentation is important because it shows that everything was done.
During the interview on 10/06/2023 at 8:32 a.m. with ADON, ADON stated that missing documentation on 9/25/2023 indicated that the task was not done and that missing monitoring for side effects of antipsychotic medication put Resident 97 at risk for psychotropic drug related complications.
A review of Facility Policy named Psychotropic Medication Use, revised in May 2023, stated residents receiving psychotropic medication are monitored for adverse consequences.
A review of Facility Policy named Charting and documentation, revised in May 2023, stated All services provided to the resident, progress toward the care plan goals . shall be documented in the resident's medical record.
Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive plan of care with measurable objectives and interventions for six of six sampled residents (Resident 57, 88, 97, 101, 123, and 281) by:
1.
Failing to develop a care addressing Resident 57's pain management.
2.
Failed to implement Resident 88's care plan interventions of monitoring of medication, vital signs, and behavior on 9/28/2023.
3.
Failing to implement Resident 97's care plan interventions to monitor for side effects of antipsychotic (medication for mental disorders) medication on 9/25/2023.
4.
Failing to develop a care plan addressing Resident 101's smoking.
5.
Failing to develop care plan for addressing Resident 123's activities.
6.
Failing to ensure Resident 281 had a care plan that addressed the resident's use of urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely).
These deficient practices placed the residents at risk for not receiving the necessary services and treatment to meet their medical, physical, mental, and psychosocial needs.
Findings:
a. A review of Resident 57's admission Record indicated the facility admitted Resident 57 on 7/16/2023 and readmitted the resident on 9/24/2023, with diagnoses including partial traumatic amputation (loss of a body part) of right foot, peripheral vascular disease (a systemic disorder that involves the narrowing of peripheral blood vessels [vessels situated away from the heart of the brain]), and diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly).
A review of Resident 57's History and Physical (H&P), dated 7/17/2023, indicated Resident 57 had the capacity to understand and make decisions.
A review of Resident 57's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/23/2023, indicated Resident 57 had the ability to make self-understood and understand others.
The MDS indicated Resident 57 was assessed for presence of occasional pain and rated pain at 4/10 on the numeric rating scale of 0 (no pain) to 10 (worst pain). The MDS also indicated Resident 57 was on an opioid (drugs with pain relieving properties that are used primarily to treat pain).
A review of Resident 57's Order Summary Report indicated an order of:
-Monitor for pain prior, during, and after treatment every day shift on 8/26/2023.
-Acetaminophen oral tablet 500 milligrams) (mg, a unit of mass or weight) (Acetaminophen, is a pain reliever and fever reducer). Give 2 tablets by mouth every 4 hours as needed for mild pain 1 to 3/10 on 9/24/2023.
-Ibuprofen oral tablet 600 mg (Ibuprofen, a medication used to manage and treat inflammatory diseases, mild to moderate pain, fever etc.). Give 1 tablet by mouth every 8 hours as needed for moderate pain 4 to 6/10 on 9/24//2023.
-Oxycodone-Acetaminophen oral tablet 5-325 mg (Oxycodone w/ Acetaminophen, used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated). Give 1 tablet by mouth every 4 hours as needed for sever pain- worst pain 7 to 10/10 on 9/24/2023.
During a concurrent interview and record review on 10/4/2023, at 2:39 p.m., reviewed Resident 57's care plans with Licensed Vocational Nurse 6 (LVN 6). LVN 6 stated the resident was on pain management program. LVN 6 stated the resident did not have a care plan for pain management. LVN 6 stated it was important to have a care plan for pain management to make sure the resident was not in pain and the pain was controlled.
A review of the facility's recent policy and procedure titled Care Plans, Comprehensive Person Centered, last reviewed on 5/2023, 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.
f. A review of Resident 281's admission Record indicated the facility admitted the resident on 9/24/2023 and readmitted on [DATE] with diagnoses including congestive heart failure (CHF - a condition that develops when your heart doesn't pump enough blood for your body's needs), pneumonia (an infection of the lungs), and generalized muscle weakness.
A review of Resident 281's H&P, dated 9/25/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 281's MDS, dated [DATE], indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance from staff with eating, and oral hygiene, substantial assistance with personal hygiene, and dependent to staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a concurrent interview and record review on 10/4/2023 at 10:42 a.m., Resident 281's care plan was reviewed with the MDS Coordinator (MDSC). The MDSC stated and verified that there was documented evidence that a care plan was developed to address the use of urinary catheter. The MDSD stated the care plan should have been developed for the use of the urinary catheter. The MDSD stated the care plan is developed so that the staff will be aware of how to properly provide care and implement interventions necessary for the care of the resident. The MDSD stated she is responsible for developing the comprehensive care plans.
A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, reviewed 5/2023, indicated a policy statement that 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 policy indicated the comprehensive care plan will:
1.
Include measurable objectives and timeframes.
2.
Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
3.
Incorporate identified problem areas.
4.
Incorporate risk factors associated with identified problems.
b. A review of Resident 88's admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and 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 88's MDS, dated [DATE], indicated Resident 88 was cognitively intact (able to understand and make decisions) and had diagnoses including anxiety disorder, depression, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
A review of Resident 88's Order Summary Report indicated Resident 88 was ordered the following medications on 9/13/2023:
-
Duloxetine (medication used to treat depression and anxiety) 60 milligrams (mg - unit of measure) one capsule by mouth two times a day for depression manifested by facial sadness.
-
Quetiapine (also known as Seroquel, medication used to treat schizophrenia, bipolar disorder, and depression) 200 mg one tablet by mouth one time a day for bipolar disorder manifested by calm to hostile behavior.
-
Quetiapine 50 mg one tablet by mouth in the evening for bipolar disorder manifested by calm to hostile behavior.
-
Trazadone (medication used to treat depression) 150 mg one tablet by mouth in the evening for depression manifested by inability to sleep.
A review of Resident 88's Care Plans, dated 9/27/2023 and 9/28/2023, indicated Resident 88 used Trazadone, Duloxetine, and Quetiapine. Resident 88's care plans included the following interventions:
-
Trazodone: monitor side effects: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia (heart rate greater than 100 beats per minute), muscle tremor, agitation, headache, skin rash, weight gain every shift.
-
Monitor behavior episodes of calm to hostile.
-
Monitor vital signs every shift.
-
Monitor behavior episodes of depression manifested by facial sadness.
A review of Resident 88's Medication Administration Record (MAR), dated 9/28/2023, between 7:00 a.m. to 3:00 p.m., indicated the following interventions were not completed:
-
Trazodone monitor side effects: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, weight gain every shift.
-
Monitor behavior episodes of calm to hostile.
-
Monitor vital signs every shift.
-
Monitor behavior episodes of depression manifested by facial sadness.
During a concurrent interview and record review with the Quality Assurance Nurse (QA), on 10/5/2023, at 9:01 a.m., Resident 88's MAR, dated 9/28/2023, between 7:00 a.m. to 3:00 p.m., was reviewed and indicated the following:
-
Trazodone monitor side effects: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, weight gain every shift.
-
Monitor behavior episodes of calm to hostile.
-
Monitor vital signs every shift.
-
Monitor behavior episodes of depression manifested by facial sadness.
The QA confirmed the interventions were not completed and stated if the documentation was not completed, it was not done. The QA stated it is important for the monitoring to be completed because if the resident is experiencing any adverse effects, the physician can be notified.
During an interview with the Director of Nursing (DON), on 10/6/2023, at 5:33 p.m., the DON stated medication monitoring should be conducted in a timely manner to check for adverse reactions and to see the effectiveness of the medications.
A review of facility's P&P titled, Psychotropic Medication Use, reviewed 5/2023, indicated residents receiving psychotropic medication are monitored for adverse consequences.
A review of facility's P&P titled, Charting and documentation, reviewed 5/2023, indicated All services provided to the resident, progress toward the care plan goals . shall be documented in the resident's medical record.
C. A review of Resident 123's admission Record indicated Resident 123 was admitted to the facility on [DATE] with diagnoses including endocarditis (an infection of the heart's inner lining, usually involving the heart valves) and generalized muscle weakness.
A review of Resident 123's MDS, dated [DATE], indicated Resident 123 was cognitively intact and it was very important for the resident to listen to the music he likes, do things with groups of people, keep up with the news, and do his favorite activities.
A review of Resident 123's Care Plans, initiated on 9/12/2023, indicated Resident 123 preferred independent activity. Resident 123's care plan indicated interventions included to provide Resident 123 with materials for individual activities as desired. The care plan intervention did not indicate what independent activities Resident 123's liked. The care plan intervention did not indicate what television channels Resident 123 preferred.
During a concurrent interview and record review with the Activities Director (AD), on 10/5/2023, at 1:52 p.m., Resident 118's Care Plan, initiated on 9/12/2023, indicated Resident 123's preferred activities. The AD stated she helped develop Resident 123's care plans. The AD stated when a resident mentions an activity they would like to participate in, the care plan would be revised to include that activity. The AD stated she did not indicate Resident 123's independent activities he liked. The AD stated she did not include Resident 123's preferred television channels. The AD stated care plans should be effective and person-centered. The AD stated she should be filling out a resident's likes and television channel preferences to create a care plan that is more person-centered. The AD stated it is important for activity care plans to be person-centered to maintain a resident's involvement in cognitive stimulation and to make sure the residents are not bored.
During an interview with the DON, on 10/6/2023, at 5:33 p.m., the DON stated care plans should be person-centered and activities care plans should be specific and person-centered.
A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, reviewed 5/2023, indicated care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The P&P further indicated the comprehensive, person-centered care plan will reflect the resident's expressed wishes regarding care and treatment goals.
A review of the facility's P&P titled, Activity Programs, reviewed 5/223, indicated individualized and group activities are provided that reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents.
e. A review of Resident 101's admission Record indicated the facility admitted the resident on 7/16/2023 with diagnoses including acute (sudden) osteomyelitis (a condition where there is inflammation and swelling in a bone), left ankle and foot and type II diabetes mellitus (a disease when the body does not produce enough insulin [blood sugar] to function properly, or the body's cells don't react to insulin).
A review of Resident 101's History and Physical, dated 9/22/2023, indicated the resident has the capacity to understand and make decisions.
During a concurrent interview and record review of Resident 101's assessments and care plans, on 10/5/2023 at 10:28 a.m., the MDSN 1 stated Resident 101's Smoking Assessment, dated 9/1/23, indicated supervision when smoking. MDSN 1 stated there is no smoking care plan developed after the assessment was done. MDSN 1 stated the care plan is important for the resident's safety and in determining the assistance the resident needs when smoking. MDSN 1 stated when the smoking care plan is not developed the facility staff can overlook the needs and safety of the residents. MDSN 1 stated the resident had the potential to burn himself.
During an interview on 10/6/2023 at 1:59 p.m., the Assistant Director of Nursing (ADON) stated a care plan addressing the resident's smoking should have been developed in order to implement interventions to keep the resident safe.
A review of the facility's policy and procedure titled, Smoking Policy - Residents, approved on 5/2023, indicated the interdisciplinary team (IDT) shall create a smoking care plan for the resident.
A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, approved on 5/2023, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs this developed and implemented for each resident. The procedure indicated that the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the residence highest practicable physical, mental, and psychosocial well-being.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with profession...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to four out of five sampled residents (Residents 29, 57, 98, and 282) by:
1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites to Residents 19 and 57.
2. Failing to rotate Lovenox (enoxaparin sodium injection) (medication that helps prevent the formation of blood clots) administration sites to Resident 98.
The deficient practices had the potential for adverse effect of same site subcutaneous administration of insulin and anticoagulant medications such as lipodystrophy (abnormal distribution of fat).
3. Failing to ensure Registered Nurse 1 (RN) indicated the administration date and time on the intravenous antibiotic (medications that are administered directly into a vein so that the medicine can enter the bloodstream immediately) bag for Resident 282.
This deficient practice placed Resident 282 for increased risk of infection.
Findings:
a. A review of Resident 29's admission Record indicated the facility admitted Resident 29 on 7/3/2010 and readmitted the resident on 12/8/2017, with diagnoses including type 2 diabetes mellitus (a group of diseases that affect how the body uses blood sugar [glucose]) with diabetic retinopathy (an eye condition that can cause vision loss and blindness in people who have diabetes) and diabetes type 2 with diabetic chronic kidney disease (high blood sugar from diabetes can damage blood vessels in the kidneys as well as nephrons so they do not work as well as they should).
A review of Resident 29's History and Physical (H&P) dated 8/24/2023, indicated Resident 29 had the capacity to understand and make decisions.
A review of Resident 29's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/13/2023, indicated Resident 29 had the ability to make self-understood and understand others. The MDS indicated Resident 29 was receiving insulin injections.
A review of Resident 29's Order Summary Report indicated an order of:
-Insulin NPH Isophane & regular Suspension (70-30) 100 unit per milliliters (unit/ml, unit of fluid volume). Inject 12 unit subcutaneously two times a day for diabetes mellitus (DM) on 12/24/2022.
-Novolin R injection Solution (Insulin Regular [Human]). Inject as per sliding scale: if 0-80 if conscious, give 4 ounces (oz, unit of weight) of juice. If unconscious, give glucagon 1 mg intramuscular (IM, within or into the muscle) X 1, notify MD; 81-199= 0 No coverage; 200-250= 2 units; 251-300= 4 units; 301-350= 6 units; 351-400= 8 units; 401+= 10 units. Notify MD, subcutaneously before meals and at bedtime for DM.
A review of Resident 29's Location of Administration Report from 7/2023 to 10/2023 indicated insulin was administered:
-Novolin R injection Solution (Insulin Regular [Human]).
7/3/2023 8:16 a.m. at the Abdomen-Left Lower Quadrant (LLQ)
7/3/2023 8:24 p.m. at the Abdomen-LLQ
7/10/2023 11:57 a.m. at the Abdomen-LLQ
7/10/2023 8:54 p.m. at the Abdomen-LLQ
7/22/2023 8:48 p.m. at the Arm-right
7/23/2023 3:15 p.m. at the Arm-right
7/23/2023 1:21 p.m. at the Arm-right
7/24/2023 4:47 p.m. at the Abdomen-LLQ
7/24/2023 10:26 p.m. at the Abdomen-LLQ
7/28/2023 8:02 p.m. at the Arm-right
7/29/2023 11:45 a.m. at the Arm-right
7/29/2023 8:22 p.m. at the Arm-left
7/30/2023 7:4 9a.m. at the Arm-left
7/30/2023 10:39 a.m. at the Arm-left
8/17/2023 3:47 p.m. at the Abdomen-Right Lower Quadrant (RLQ)
8/17/2023 8:27 a.m. at the Abdomen-RLQ
8/18/2023 8:14 p.m. at the Abdomen-RLQ
8/19/2023 11:03 a.m. at the Abdomen -RLQ
8/22/2023 10:46 a.m. at the Abdomen-LLQ
8/22/2023 8:26 p.m. at the Abdomen-LLQ
8/23/2023 11:41 a.m. at the Abdomen-LLQ
8/23/2023 8:11 p.m. at the Arm-right
8/24/2023 12 p.m. at the Arm-right
8/28/2023 4:49 p.m. at the Arm-right
8/28/2023 8:34 p.m. at the Arm-right
9/3/2023 11:25 a.m. at the Abdomen-LLQ
9/3/2023 4:49 p.m. at the Abdomen-LLQ
9/9/2023 8:42 p.m. at the Arm-right
9/10/2023 11:53 a.m. at the Arm-right
9/11/2023 4:51 p.m. at the Abdomen-LLQ
9/11/2023 9 p.m. at the Abdomen-LLQ
9/13/2023 7:47 a.m. at the Abdomen-LLQ
9/13/2023 12:22 p.m. at the Abdomen-LLQ
9/14/2023 8:27 a.m. at the Arm-right
9/14/2023 11:50 a.m. at the Arm-right
9/14/2023 8:35 p.m. at the Arm-right
9/15/2023 11:47 a.m. at the Arm-right
9/16/2023 8:10 a.m. at the Arm-right
9/20/2023 7:43 a.m. at the Abdomen-LLQ
9/20/2023 12:09 p.m. at the Abdomen-LLQ
9/21/2023 8:24 p.m. at the Arm-right
9/22/2023 11:16 a.m. at the Arm-right
9/28/2023 8:03 p.m. at the Arm-right
9/29/2023 11:20 a.m. at the Arm-right
9/30/2023 9:23 a.m. at the Arm-right
9/30/2023 11:27 a.m. at the Arm-right
9/30/2023 3:52 p.m. at the Arm-right
9/30/2023 9:15 p.m. at the Arm-right
10/2/2023 11:32 a.m. at the Abdomen-LLQ
10/2/2023 11:57 a.m. at the Abdomen-LLQ
-Insulin NPH Isophane & regular Suspension (70-30) 100 unit/ml.
7/3/2023 9:40 a.m. at the Abdomen-LLQ
7/3/2023 4:12 p.m. at the Abdomen-LLQ
7/24/2023 9:35 a.m. at the Abdomen-LLQ
7/24/2023 4:51 p.m. at the Abdomen-LLQ
7/29/2023 4:24 p.m. at the Abdomen-RLQ
7/30/2023 8:39 a.m. at the Abdomen-RLQ
8/13/2023 8:17 a.m. at the Abdomen-RLQ
8/13/2023 5:01 p.m. at the Abdomen-RLQ
9/20/2023 4:02 p.m. at the Abdomen-LLQ
9/21/2023 8:53 a.m. at the Abdomen-LLQ
10/1/2023 4:08 p.m. at the Abdomen-LLQ
10/2/2023 8:32 a.m. at the Abdomen-LLQ
A review of Resident 57's admission Record indicated the facility admitted Resident 57 on 7/16/2023 and readmitted the resident on 9/24/2023, with diagnosis including type 2 diabetes mellitus with foot ulcer (open sores or lesions that will not heal or that return over a long period of time).
A review of Resident 57's H&P, dated 7/17/2023, indicated Resident 57 had the capacity to understand and make decisions.
A review of Resident 57's MDS, dated [DATE], indicated Resident 57 had the ability to make self-understood and understand others. The MDS indicated Resident 57 was receiving insulin injections.
A review of Resident 57's Order Summary Report indicated an order of:
-Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject 7 unit subcutaneously with meals for diabetes type 2 (DM2) hold if blood sugar (BS) less than 70 on 9/30/2023.
-Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 51-200= 1-unit sq; 201-250= 2 units; 251-300= 3 units sq; 301-350= 4 units sq; 351-400= 6 units sq, subcutaneously before meals for DM2 hold if BS less than 70 on 9/30/2023.
A review of Resident 57's Location of Administration Report from 7/2023 to 10/2023 indicated insulin was administered:
-Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro).
9/25/2023 8:04 a.m. at the Abdomen-LLQ
9/25/2023 8:04 a.m. at the Abdomen-LLQ
9/25/2023 12:07 p.m. at the Abdomen-LLQ
9/25/2023 12:06 p.m. at the Abdomen-LLQ
9/26/2023 12:00 p.m. at the Abdomen-LLQ
9/26/2023 4:40 p.m. at the Abdomen-LLQ
9/27/2023 9:08 a.m. at the Abdomen-LLQ
9/27/2023 9:08 a.m. at the Abdomen-LLQ
9/27/2023 11:59 a.m. at the Abdomen-LLQ
9/27/2023 11:59 a.m. at the Abdomen-LLQ
10/4/2023 11:48 a.m. at the Abdomen-LLQ
10/4/2023 4:18 p.m. at the Abdomen-LLQ
During a concurrent interview and record review on 10/4/2023, at 11:32 a.m., with the Infection Preventionist (IP), reviewed Residents 29 and 57's medical records. The IP stated there were a lot of repeated insulin administrations sites to both residents between 7/2023 to 10/2023. The IP stated the administration sites should be rotated because repeated insulin administration on the same site could lead to muscle wasting and lipodystrophy.
During an interview on 10/6/2023, at 10:05 a.m., the Director of Staff Development (DSD) stated the licensed nurses should have rotated the site of insulin administration to prevent complications such as bruising and hardening of injection site.
During an interview on 10/6/2023, at 10:28 a.m., the Director of Nursing (DON) stated the insulin administration sites should be rotated to prevent lipodystrophy.
b. A review of Resident 98's admission Record indicated the facility admitted Resident 98 on 7/31/2023, with diagnoses including heart disease and cerebral infarction (occurs because of disrupted blood flow to the brain due to problems within the blood vessels that supply it).
A review of Resident 98's MDS, dated [DATE], indicated Resident 98 had the ability to make self-understood and understand others. The MDS indicated Resident 98 was on an anticoagulant (a substance that hinders the clotting of blood) medication.
A review of Resident 98's Order Summary Report indicated the following orders:
-Enoxaparin Sodium Injection Solution Prefilled Syringe 40 milligrams (mg, a unit of weight)/0.4 milliliters (ml, a unit of volume) (Enoxaparin Sodium). Inject 0.4 ml subcutaneously one time a day for deep vein thrombosis (DVT, formation of one or more blood clots in one of the body's large veins, most commonly in the lower limb) prophylaxis (prevention of a specific disease). Rotate site.
-Anticoagulant medication- monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting (N&V), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs (v/s, the heart rate, breathing or respiratory rate, blood pressure, and temperature), shortness of breath (SOB), nose bleeds on 8/1/2023.
A review of Resident 98's Location of Administration Report from 7/2023 to 10/2023 indicated enoxaparin subcutaneous injection site was administered on:
8/1/2023 10:21 a.m. at the Abdomen-LLQ
8/2/2023 10:03 a.m. at the Abdomen-LLQ
8/20/2023 10:08 a.m. at the Abdomen-LUQ
8/23/2023 9:57 a.m. at the Abdomen-LUQ
8/29/2023 10:47 a.m. at the Abdomen-LLQ
9/1/2023 12:15 p.m. at the Abdomen-LLQ
9/5/2023 9:39 a.m. at the Abdomen-LLQ
9/6/2023 9:34 a.m. at the Abdomen-LLQ
9/10/2023 11:20 a.m. at the Abdomen-LUQ
9/12/2023 9:27 a.m. at the Abdomen-LUQ
10/2/2023 9:42 a.m. at the Abdomen-LLQ
10/3/2023 9:20 a.m. at the Abdomen-LLQ
A review of Resident 98's Care Plan, initiated on 8/16/2023, indicated Resident 98 was on an anticoagulant therapy- Enoxaparin Sodium Injection Solution Prefilled Syringe 40 mg/0.4 ml with an intervention to administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every (q) shift.
During a concurrent interview and record review on 10/4/2023, at 11:32 a.m., reviewed Resident 98's medical records with the IP. The IP stated the enoxaparin subcutaneous medication was administered repeatedly on the same site between 7/2023 to 10/2023. The IP stated the staff should have rotated the site of administration to prevent bruising and lipodystrophy.
During an interview on 10/6/2023, at 10:05 a.m., the DSD stated the staff should have rotated the site of enoxaparin subcutaneous injection administration due to complications of bruising and hardening of the site of injection.
During an interview om 10/6/2023, at 10:28 a.m., the DON stated the enoxaparin subcutaneous injection administration site should be rotated to prevent lipodystrophy.
A review of the facility's recent policy and procedure titled Insulin Administration, last reviewed on 5/2023, indicated injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm)
A review of the Manufacturer's Guidelines on the use of Enoxaparin Sodium Injection, USP for subcutaneous and intravenous use with initial U.S. approval in 1993, indicated to alternate injection sites between the left and right anterolateral and left and right posterolateral abdominal wall. During therapy monitor complete blood counts including platelets and stool occult blood. Assess for signs and symptoms of bleeding.
A review of the facility's provided Physician's Desk Reference- Insulin Lispro, undated, indicated to rotate injection sites within the same region with each injection to prevent lipodystrophy and localized cutaneous amyloidosis. Do not inject into areas of lipodystrophy or localized cutaneous amyloidosis.
c. A review of Resident 282's admission Record indicated the facility admitted the resident on 9/18/2023 and readmitted on [DATE] with diagnoses including osteomyelitis (inflammation or swelling that occurs in the bone), epilepsy (a condition that affects the brain and causes frequent seizures), and generalized muscle weakness.
A review of Resident 282's History and Physical dated 9/19/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 282's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/25/2023, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision from staff with eating, limited assistance with bed mobility, and extensive assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 282's Order Summary Report indicated the following orders:
1.
Zosyn intravenous (IV)solution reconstituted 3.375 grams (gm - a unit of measurement) with order date 9/18/2023 use 3.375 gm intravenously every eight hours for osteomyelitis until 10/06/2023.
2.
Daptomycin IV solution reconstituted 350 milligrams (mg - a unit of measurement) with order date 9/18/2023 use 350 mg intravenously in the afternoon for osteomyelitis until 10/06/2023.
During a concurrent observation and interview on 10/3/2023 at 8:48 a.m., Resident 282 was sitting up in bed, alert, and answered questions appropriately. Observed an empty bag of Zosyn hanging on an IV pole with no date and time indicated when the medication was administered. Resident 282 stated he is receiving IV antibiotics to treat the wound infection on his chest from the surgery.
During a concurrent interview and record review on 10/3/2023 at 8:51 a.m., the Assistant Director of Nursing (ADON) verified that the bag hanging on the IV pole was Zosyn and did not indicate the date and time the medication was administered. The ADON stated the RN during the previous shift should have indicated the date and time the medication was administered. The ADON stated it was important to indicate the date and time the IV medication was administered so the other RNs would know if the IV tubing needed to be changed. The ADON stated that the IV tubing used to infuse the medication need to be changed every 24 hours for intermittent infusion per facility practice.
During an interview on 10/6/2023 at 9:13 a.m., the Infection Preventionist stated the IV antibiotic bag should indicate the date and time of the administration and the initials of the RN who administered the medication. The IP stated it was important to date the IV antibiotic bag, so the RNs know when the medication was administered and when to change the IV tubing.
A review of the facility's policy and procedure titled, Intravenous Therapy Medication Record, last reviewed 5/2023, indicated a purpose to facilitate accurate and timely documentation of the various procedures and activities involved with the infusion therapy. The policy indicated to enter the start and stop date and write in the actual start time and initial.
A review of the facility's policy and procedure titled, Intravenous Administration of Fluids and Electrolytes, last reviewed 5/2023 indicated to mark the solution container with label that states when the bag was started.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to provide appropriate treatment and services for t...
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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 provide appropriate treatment and services for three (Resident 102, 117, and 76) of four sampled residents with an indwelling urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) by:
1. Failing to provide daily catheter care and catheter assessments to Residents 102 and 117.
2. Failing to place a catheter tubing securement device (to secure an indwelling urinary catheter) on Resident 117.
3. Failing to assess Resident 76 prior to placement of an indwelling urinary catheter.
These deficient practices had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder).
Findings:
a. A review of Resident 102's admission Record indicated the facility admitted Resident 102 on 11/29/2022 and readmitted the resident on 4/11/2023, with diagnoses including proteus mirabilis morganii (commonly found in the environment in the intestinal tract of humans, mammals, and reptiles), retention of urine, and sepsis (the body's extreme response to an infection).
A review of Resident 102's History and Physical (H&P), dated 4/12/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 102's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/26/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required extensive assistance on bed mobility, dressing, toilet use, and personal hygiene with one to two-persons assistance. The MDS indicated Resident 102 was always incontinent of bowel (feces).
A review of Resident 102's Order Summary Report indicated the following orders:
-Catheter - Type: Indwelling on 4/11/2023.
-Catheter- catheter care every (q) shift on 4/11/2023.
-Catheter- change foley catheter (a thin, flexible catheter used specially to drain urine from the bladder by way of the urethra) once monthly and as needed for dislodged/leaking on 10/3/2023.
-Catheter- change if needed (PRN) for infection, blockage or dislodge, or when the closed system is compromised as needed on 4/12/2023.
-Catheter-change urinary drainage bag PRN for infection, obstruction, or when closed system is compromised every shift on 4/12/2023.
-Catheter- connected to drainage bag. French size: (Fr, based upon measurement of the external diameter of the catheter tube) 16 bulb: 10 milliliter (ml, a unit of volume) on 4/11/2023.
-Catheter- may apply leg strap (designed to support the urinary catheter and the catheter leg bag) to prevent pulling of the catheter tubing on 4/11/2023.
-Catheter- monitor indwelling catheter for signs and symptoms (s/s) of urinary tract infection (UTI): amber color urine, foul urine odor, poor urine output, sediments (the matter that settles to the bottom of a liquid) every shift on 4/11/2023.
-Catheter- monitor leg strap for placement daily and PRN on 4/11/2023.
A review of Resident 102's Medication Administration Record (MAR) indicated missing entries of assessment of catheter care every shift on the following dates and shifts:
8/5/2023 11 p.m. to 7 a.m. shift
8/6/2023 3 p.m. to 11 p.m. shift
8/13/2023 3 p.m. to 11 p.m. shift
9/10/2023 7 a.m. to 3 p.m. shift
9/12/2023 11 p.m. to 7 a.m. shift
9/18/2023 3 p.m. to 11 p.m. shift
9/19/2023 11 p.m. to 7 a.m. shift
9/24/2023 3 p.m. to 11 p.m. shift
A review of Resident 102's Medication Administration Record (MAR) indicated missing entries of assessment for the order: Catheter-change urinary drainage bag PRN for infection, obstruction, or when closed system is compromised every shift, on the following dates and shifts:
8/5/2023 11 p.m. to 7 a.m. shift
8/6/2023 3 p.m. to 11 p.m. shift
8/13/2023 3 p.m. to 11 p.m. shift
9/10/2023 7 a.m. to 3 p.m. shift
9/12/2023 11 p.m. to 7 a.m. shift
9/18/2023 3 p.m. to 11 p.m. shift
9/19/2023 11 p.m. to 7 a.m. shift
9/24/2023 3 p.m. to 11 p.m. shift
A review of Resident 102's Medication Administration Record (MAR) indicated missing entries of assessment for the order: Catheter- monitor indwelling catheter for s/s of UTI: amber color urine, foul urine odor, poor urine output, sediments every shift, on the following dates and shifts:
8/6/2023 3 p.m. to 11 p.m. shift
8/13/2023 3 p.m. to 11 p.m. shift
9/10/2023 7 a.m. to 3 p.m. shift
9/12/2023 11 p.m. to 7 a.m. shift
9/18/2023 3 p.m. to 11 p.m. shift
9/19/2023 11 p.m. to 7 a.m. shift
9/24/2023 3 p.m. to 11 p.m. shift
b. A review of Resident 117's admission Record indicated the facility admitted the resident on 8/10/2023, with diagnoses including pressure ulcer of left buttock stage 4 (full thickness loss with exposed bone, tendon, or muscle), benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged and not cancerous), and unstageable (stage is not clear) pressure injury on the sacral region.
A review of Resident 117's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 117 needed extensive assistance with bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, and personal hygiene with one to two-persons assistance. The MDS indicated the resident was occasionally incontinent of bowel.
A review of Resident 117's Order Summary Report indicated the following orders:
-Catheter- catheter care q shift on 8/10/2023.
-Catheter- change PRN for infection, blockage or dislodge, or when the closed system is compromised on 8/10/2023.
-Catheter- change urinary drainage bag PRN for infection, obstruction, or when the closed system, is compromised as needed on 8/10/2023.
-Catheter- may apply leg strap to prevent pulling of the catheter tubing every shift on 8/10/2023.
-Catheter- monitor indwelling catheter for s/s of UTI: amber color urine, foul urine odor, poor urine output, sediments every shift on 8/10/2023.
-Catheter- monitor leg strap for placement daily and PRN every shift on 8/10/2023.
A review of Resident 117's Medication Administration Record (MAR) indicated missing entries of assessment for the order: Catheter- catheter care q shift on the following dates and shifts:
8/13/2023 3 p.m. to 11 p.m. shift
9/10/2023 7 a.m. to 3 p.m. shift
9/12/2023 11 p.m. to 7 a.m. shift
9/18/2023 3 p.m. to 11 p.m.
9/24/2023 3 p.m. to 11 p.m.
10/3/2023 11 p.m. to 7 a.m.
A review of Resident 117's Medication Administration Record (MAR) indicated missing entries of assessment for the order: Catheter- may apply leg strap to prevent pulling of the catheter tubing every shift on the following dates and shifts:
8/13/2023 3 p.m. to 11 p.m. shift
9/10/2023 7 a.m. to 3 p.m. shift
9/12/2023 11 p.m. to 7 a.m. shift
9/18/2023 3 p.m. to 11 p.m.
9/24/2023 3 p.m. to 11 p.m.
10/3/2023 11 p.m. to 7 a.m.
A review of Resident 117's Medication Administration Record (MAR) indicated missing entries of assessment for the order: Catheter- monitor indwelling catheter for s/s of UTI: amber color urine, foul urine odor, poor urine output, sediments every shift on the following dates and shifts:
8/13/2023 3 p.m. to 11 p.m. shift
9/10/2023 7 a.m. to 3 p.m. shift
9/12/2023 11 p.m. to 7 a.m. shift
9/18/2023 3 p.m. to 11 p.m.
9/24/2023 3 p.m. to 11 p.m.
10/3/2023 11 p.m. to 7 a.m.
A review of Resident 117's Medication Administration Record (MAR) indicated missing entries of assessment for the order: Catheter- monitor leg strap for placement daily and PRN every shift on the following dates and shifts:
8/13/2023 3 p.m. to 11 p.m. shift
9/10/2023 7 a.m. to 3 p.m. shift
9/12/2023 11 p.m. to 7 a.m. shift
9/18/2023 3 p.m. to 11 p.m.
9/24/2023 3 p.m. to 11 p.m.
10/3/2023 11 p.m. to 7 a.m.
During a concurrent interview and record review on 10/4/2023, at 9:24 a.m., reviewed Resident 102 and Resident 117's medical records with Licensed Vocational Nurse 10 (LVN 10). LVN 10 stated there were missing assessments and documentations from 8/2023 to 10/2023 on catheter care, monitoring for signs and symptoms of UTI, and the application of a leg strap for Residents102 and Resident 117, who both had indwelling catheters. LVN stated it was important to provide daily catheter care and monitor for signs and symptoms of infection on residents with catheter to prevent CAUTI.
During a concurrent observation, interview, and record review on 10/4/2023, at 11:25 a.m., observed with LVN 10 and Licensed Vocational Nurse 5 (LVN 5) Resident 117's urinary catheter not secured with a leg strap or a securement device. LVN 10 stated the importance of having a leg strap or securement device on a resident with urinary catheter was to prevent the catheter from tugging and pulling causing trauma to the urinary meatus (the opening in the penis where urine comes out) that could cause an infection.
During an interview on 10/4/2023, at 11:32 a.m., the Infection Preventionist (IP) stated catheter care must be provided to residents with urinary catheter daily and as needed. The IP stated licensed staff should be assessing the urinary catheter for signs of infection as ordered by the physician. The IP stated the securement device prevents trauma to the tissues of the urinary opening catheter by preventing pulling.
During an interview on 10/6/2023, at 10:05 a.m., the Director of Staff Development (DSD) stated the purpose of having a securement device or the leg strap on a resident with a urinary catheter was to prevent the catheter from pulling or kinking which could cause trauma to the urinary opening and infection. The DSD stated daily catheter care prevents CAUTI to residents.
During an interview on 10/6/2023, at 10:28 a.m., the Director of Nursing (DON) stated daily catheter care helps prevent ascending infection to residents who have urinary catheter. The DON stated it was important to secure the urinary catheter with a securement device or a leg strap to prevent the catheter from pulling the urinary meatus, which could cause an infection.
A review of the facility's recent policy and procedure titled Catheter Care, Urinary, last reviewed on 5/2023, indicated the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.
A review of the facility's recent policy and procedure titled Indwelling (Foley) Catheter Insertion, Male Resident, last reviewed on 5/2023, indicated the purpose of this procedure is to provide guidelines for the aseptic insertion of an indwelling (Foley) urinary catheter in a male resident. Secure catheter tubing and/or bag to resident with approved catheter securement device.
c. A review of Resident 76's admission Record indicated the facility admitted the resident on 1/24/2023 with diagnoses including UTI and retention of urine.
A review of Resident 76's History and Physical, dated 12/20/2022, indicated the resident has the capacity to understand and make decisions.
A review of Resident 76's Physician Orders, dated 7/3/2023, indicated the following orders:
-
Catheter - monitor indwelling catheter care for signs and symptoms of UTI: dark amber color urine, foul urine odor, poor urine output, and sediments every day shift.
-
Catheter - catheter care every shift, every shift, every day shift.
A review of Resident 76's MDS, dated [DATE], indicated the resident is cognitively intact and required extensive assistance with bed mobility, locomotion on unit, dressing, toilet use, and personal hygiene with one-person physical assist. The MDS indicated the resident required total dependence with transfer with two-persons physical assist. The MDS indicated the resident had indwelling catheter and did not have a trial of toileting program (e.g. scheduled toileting, prompted voiding, or bladder training).
A review of Resident 76's Bowel and Bladder Assessment, dated 7/26/2023, indicated the resident is always incontinent of urine with no predisposing factors. The assessment did not indicate the type of incontinence Resident 76 has.
During a concurrent observation and interview on 10/3/2023 at 8:45 a.m., observed Resident 76 with an indwelling catheter. The resident stated he has had the indwelling urinary catheter since July 2023 and was told by staff he has urinary retention. The resident stated he does not know how long he is going to have the indwelling urinary catheter in and when they plan to remove it. The resident stated every time he tells a Certified Nursing Assistant (CNA) or a charge nurse to help him empty his urinary catheter bag, the staff acted like they were not aware he has a urinary catheter.
During a concurrent interview and record review of Resident 76's clinical record on 10/5/2023 at 10:47 a.m., the MDSN 1 stated there was no change of condition assessment completed for the resident's use of the indwelling urinary catheter.
During an interview on 10/5/2023 at 2:38 p.m., Licensed Vocational Nurse 5 (LVN 5) stated she does not know what the reason was for Resident 76's indwelling urinary catheter use. LVN 6 stated the charge nurse asked her to document the order on behalf of the charge nurse.
During an interview on 10/6/2023 at 1:46 p.m., the Assistant Director of Nursing (ADON) stated it is a change of condition when the physician ordered a urinary indwelling catheter for a resident who did not use to have a urinary indwelling catheter. The ADON stated it is the charge nurse's responsibility to complete the change in condition form and to notify the registered nurse supervisor and the physician, and resident's hospice nurse. The ADON stated it is important to complete the change in condition assessment in order to develop and implement care plan interventions to prevent bladder distention and urinary tract infection and keep the resident free from discomfort.
A review of the facility's policy and procedure titled, Urinary Incontinence - Clinical Protocol, approved on 5/2023, indicated the physician will identify potentially treatable medical and psychiatric conditions related to your urinary incontinence. The physician will order appropriate diagnostic tests such as urinalysis, measuring post void residual, or referral for a cystoscopy or cystometrogram the physician will categorize incontinence as urge stress overflow or functional. The procedure indicated the physician will identify and document clinically pertinent reasons why an indwelling urethral is indicated and will document why other alternatives are not feasible the procedure indicated the staff and physician will review the progress of individuals with impaired continents until continence is restored or improved as much as possible or it is identified that further improvement is unlikely. This should include a documentation of a resident's responses to attempted interventions such as scheduled toileting, prompted voiding, or medications used to treat incontinence.
A review of the facility's policy and procedure titled, Urinary Tract Infection (Catheter-Associated), Guidelines for Preventing, approved on 5/2023, indicated the procedure to insert catheters only for indications deemed appropriate for urinary catheter insertion, and as ordered the procedure indicated to leave catheters in place only as long as needed that and conduct ongoing assessment and monitoring of residents within dwelling catheters to establish continued need, document every 24 hours or per facility protocol. The procedure indicated to initiate steps to discontinue order and remove catheter if criteria is no longer met. The procedure indicated to document the continued need for the resident's indwelling catheter and any signs or symptoms of urinary tract infection.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the kitchen in a clean, safe, and sanitary c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the kitchen in a clean, safe, and sanitary condition in which food was stored, prepared, and served in accordance with professional standards of food service safety by:
1.
Failing to ensure that a pack of fresh blueberries observed with white spots was discarded.
2.
Failing to ensure an open bottle of non-alcoholic [NAME] cocktail mix was labelled with open date.
3.
Failing to ensure open bags of French fries, white bread, and yellow bread were labelled with open date.
4.
Failing to ensure yellow cheese in a container was labeled with the content and open date.
5.
Failing to ensure white cheese in a container was labelled with the content and discarded past the date indicated 9/27/2023 - 9/31/2023.
6.
Failing to ensure a bottle of a sports drink and Arizona tea belonging to a staff were not stored in the walk-in refrigerator.
7.
Failing to ensure apple sauce, pudding, green gelatin in cups prepared in advance were labelled with the date they were prepared.
8.
Failing to ensure that two cans of shoestring beans with dents on the rim were not placed in the shelf for dented cans.
9.
Failing to ensure that the scoops for the all-purpose flour, pinto beans, thickening powder, brown sugar, and parboiled rice were not left on top of the container lid.
These deficient practices had the potential to result in contamination of the food and placed the residents at risk for foodborne illnesses (illnesses caused by the ingestion of contaminated food or beverages).
Findings:
a. During a concurrent observation and interview on 10/2/2023 at 8:06 a.m. with Dietary Aide 1 (DA 1), observed the following items in the kitchen without open dates:
1.
An open bottle of non-alcoholic [NAME] cocktail mix. DA 1 stated he did not know why the bottle is there. DA 1 stated he was not sure it the bottle was supposed to be in the walk-in refrigerator.
2.
A bag each of French fries, white bread, and yellow bread were not labelled with open date and no best buy date. DA 1 stated it should be dated when opened so the staff would know when to discard the items.
3.
A bottle of sports drink and tea on the shelf inside the walk-in refrigerator. DA 1 stated the beverages belong to kitchen staff. DA 1 stated staff should not place personal food or beverages in the walk-in refrigerator.
4.
A container with yellow colored cheese was not labelled with the content and the open date. DA 1 stated the content was American cheese. DA 1 stated should indicate the content and open date so staff would know when to discard the item.
5.
A container with white cheese was not labelled with the content and discarded past the date indicated 9/27/2023 - 9/31/2023. Dietary Aide 2 (DA 2) stated 9/31/2023 was the last day to use and should have been discarded.
6.
Six apple sauce in cups, 22 puddings in cups, 24 green gelatins in cups prepared in advance were not labelled when they were prepared. DA 1 stated the apple sauce, gelatins, and puddings should indicate the date they were prepared so the staff would know when to discard the items.
7.
A pack of fresh blueberries with white spots at the bottom of the container. DA 1 stated the white spots were mold. DA 1 stated that the blueberries should have been discarded.
8.
Two cans of shoestring beans with dents on the rim were observed in the shelf with non-dented cans. DA 1 stated dented cans should have been placed in another shelf with other dented cans to be returned to the company on the next delivery day.
9.
The scoops for the all-purpose flour, pinto beans, thickening powder, brown sugar, and parboiled rice were left on top of the container lid. DA 1 stated it should not be left on top of the lid. DA 1 stated the scoops should have been washed and stored away.
During an interview on 10/5/2023 at 10:09 a.m., the Dietary Supervisor (DS) stated that dietary staff were supposed to label any newly opened items with the content, open date, and used by date so the staff would know when to discard the items. The DS stated DA 1 was supposed to discard any old or expired items and label everything in the refrigerator, freezer, and dry storage room. The DS stated dented should have been placed in a designated shelf and returned to the company for credit every delivery day. The DS stated it is important to discard dented cans because of possible botulism (a dangerous foodborne illness caused by a toxin that attacks the body's nerves) which could negatively affect the residents. The DS stated dents creates air in the can which made the food inedible.
During an interview on 10/6/2023 at 9:43 a.m., the DS stated all food items such as bread, cheese, apple sauce, puddings, gelatins, French fires should be labelled with open date so staff will know when to discard the items. The DS stated not labelling food items on when they were opened or prepared placed the residents at risk for harm or food borne illnesses if served with expired items. The DS stated the [NAME] cocktail mix can be stored in the refrigerator as it belonged to the residents during special event dinners but should be labelled with open date. The DS stated there should be no personal food item in the walk-in refrigerator. The DS stated bulk cheese placed in the container can be used within seven days but should be labelled with the content and open date. The DS stated that other packages of fresh blueberries in the same tray as the one package with mold had been discarded because they are considered contaminated, and the residents might get sick.
A review of the facility's policy and procedure titled, Labelling and Dating of Foods, last reviewed 5/2023, indicated newly opened food items will need to be closed and labelled with an open date.
A review of the facility's policy and procedure titled, Food Storage, indicated a policy statement that food items will be stored, thawed, and prepared in accordance with good sanitary practice. The Policy indicated fresh fruit should be checked and sorted for ripeness. The policy indicated dented or bulging cans should be placed in a separate area and returned for credit.
A review of the facility's policy and procedure titled, Food Storage-Dented Cans, indicated all dented cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to arrange provision of hospice services (a type of care and phi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to arrange provision of hospice services (a type of care and philosophy of care that focuses on the care of the terminally ill patients' pain and symptoms, and attending to their emotional and spiritual needs) for two of two sampled residents (Resident 76 and 124) by failing to ensure hospice staff, including registered nurse (RN), licensed vocational nurse (LVN), and hospice aide (HA) provided nursing visits based on the hospice calendar and failed to provide the hospice visitation notes to the facility.
These deficient practices had the potential to negatively affect Residents 76 and 124's physical comfort, psychosocial well-being, and not receiving the needed and necessary hospice care services timely.
Findings:
a. A review of Resident 76's admission Record indicated the facility admitted the resident on 1/24/2023 with diagnoses including severe protein calorie malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function).
A review of Resident 76's History and Physical (H&P), dated 12/20/2022, indicated the resident had the capacity to understand and make decisions.
A review of Resident 76's Physician Orders, dated 7/14/2021, indicated to admit the resident to Hospice 1 due to terminal diagnosis of severe protein calorie malnutrition, order dated 7/14/2021.
A review of Resident 76's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/20/2023, indicated the resident was cognitively (relating to thinking, reasoning, or remembering) intact and required extensive assistance with bed mobility, locomotion on unit, dressing, toilet use, and personal hygiene with one-person physical assist. The MDS indicated the resident required total assistance with transfer with two-person physical assist. The MDS indicated the resident was receiving hospice care while in the facility.
A review of Resident 76's Physician's Certification for Hospice Benefit, dated 8/31/2023, indicated the effective date of certification from 9/2/2023 to 10/31/2023 that resident had a life expectancy of six months or less if the terminal illness runs its normal course.
A review of Resident 76's Hospice 1 Plan of Care, dated 9/2/2022, indicated the following frequency of visits: hospice aide (HA) twice per week, registered nurse (RN) per two weeks and one as needed visit, and skilled nursing (SN) once per week.
During an interview on 10/3/2023 at 8:45 a.m., Resident 76 stated he was on hospice care but had not seen the hospice aide in a while. Resident 76 also stated the last hospice nurse he saw was sometime last week.
During a concurrent interview and record review of Resident 76's Hospice 1 RN Calendar, RN Visit Notes, and RN Sign-in sheets for the month of 9/2023, on 10/5/2023 at 10:10 a.m., MDS Nurse 1 (MDSN 1) stated there was an RN visit scheduled for 9/29/2023, but they were not sure if the RN did come because there were no notes from the RN. MDSN 1 stated there were also no visit notes for the month of 9/2023 of when the RN made the visit.
During a concurrent interview and record review of Resident 76's Hospice 1 SN Calendar, SN Visit Notes, and SN Sign-in sheets for the month of 9/2023, on 10/5/2023 at 10:19 a.m., MDSN 1 stated the SN signed on the Licensed Vocational Nurse (LVN) Sign-in sheets on 9/1/2023, 9/8/2023, 9/15/2023, 9/22/2023, and 9/29/2023. MDSN 1 stated the SN Visit Notes on file of the resident's clinical record were dated 9/7/2023, 9/13/2023, 9/20/2023, and 9/27/2023. MDSN 1 stated the SN sign-in sheet signatures did not match the dates of visit on the SN visit notes.
During a concurrent interview and record review of Resident 76's Hospice 1 HA Calendar, HA Visit Notes, and HA Sign-in sheets for the month of 9/2023, on 10/5/2023 at 10:23 a.m., MDSN 1 stated the HA calendar indicated HA visits were initialed on the HA calendar and sign in sheets on 9/5/2023, 9/7/2023, 9/12/2023, 9/14/2023, 9/19/2023, 9/21/2023, 9/26/2023, and 9/28/2023. MDSN 1 stated on file of Resident 76 had recent HA Visit Note dated 6/29/2023. The MDSN 1 stated there were no corresponding notes for HA visits for the month of 9/2023. The MDSN 1 stated she was not sure about when Hospice 1 need to provide their notes about their resident visits.
During an interview on 10/5/2023 at 2:39 p.m., LVN 1 stated hospice RN and hospice LVN come once a month. LVN 1 stated when the hospice staff visits, they sign-in in the hospice binder to show that they were at the facility, but he did not know who checks (reviews) the hospice binder.
During an interview on 10/6/2023 at 1:07 p.m., the Assistant Director of Nursing (ADON) stated they have their monthly calendar schedule for the scheduled hospice visits for the RN, LVN, and HA.
During an interview on 10/6/2023 at 1:21 p.m., the ADON stated the hospice staff usually document their visits and the hospice agency should provide the notes to the facility after each visit. The ADON stated if the visit notes were not in the facility, the visits were not done. The ADON stated they should address those visits to ensure the goals for comfort for the hospice residents are met.
During an interview on 10/6/2023 at 1:41 p.m., the ADON stated not being able to follow through the hospice agreement (including facility visits) translates that they are not attending to the needs of the residents.
A review of the facility's policy and procedure titled, Hospice Program, approved on 5/2023, indicated that Hospice services are available to residents at the end of life. The policy and procedures indicated hospice providers who contract with the facility must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency and are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. The policy and procedures indicated it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the resident's needs which includes, notifying the hospice about a significant change in the resident's physical mental social or emotional status; clinical complications that suggest a need to alter the plan of care; communicating with the hospice provider and documenting such communication to ensure that the needs of the residents are addressed and met 24 hours per day.
b. A review of Resident 124's admission Record indicated the facility admitted the resident on 4/24/2023 with diagnoses including basal cell carcinoma (a type of skin cancer that causes a lump, bump or lesion to form on the outside layer of the skin) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 124's Physician Orders, dated 8/7/2023, indicated to admit the resident under routine level of hospice care under Hospice 1 for pain management for diagnosis of basal cell carcinoma.
A review of Resident 124's MDS, dated [DATE], indicated the resident usually made self understood and understood others. The MDS indicated the resident required extensive assistant with bed mobility, dressing, toilet use, and personal hygiene with one-to-two-person physical assistance.
During a concurrent interview and record review of Resident 124's Hospice 1 binder, Calendar, Sign-In Sheets, and Visit Notes for the month of 8/2023, on 10/6/2023 at 10:30 a.m., the MDS Coordinator (MDSC) stated there were no documentation from RN on two visits 8/7/2023 and 8/13/2023 and no documentation and sign-in from HA as scheduled on 8/8/2023, 8/10/2023, 8/15/2023, 8/17/2023, and 8/22/2023.
During an interview on 10/6/2023 at 1:07 p.m., the ADON stated they have their monthly calendar schedule for when the hospice visits for RN, LVN, and HA.
During an interview on 10/6/2023 at 1:21 p.m., the ADON stated the hospice staff usually document their visits and the hospice agency should provide the notes to the facility after each visit. The ADON stated if the visit notes were not in the facility, the visits were not done. The ADON stated they should address those visits to ensure the goals for comfort for the hospice residents are met.
During an interview on 10/6/2023 at 1:41 p.m., the ADON stated not being able to follow through the hospice agreement (including facility visits) translates that they are not attending to the needs of the residents.
A review of the facility's policy and procedure titled, Hospice Program, approved on 5/2023, indicated that Hospice services are available to residents the end of life. The policy and procedures indicated hospice providers who contract with the facility must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency, and are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. The policy and procedures indicated it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the resident's needs which includes, notifying the hospice about a significant change in the resident's physical mental social or emotional status; clinical complications that suggest a need to alter the plan of care; communicating with the hospice provider and documenting such communication to ensure that the needs of the residents are addressed and met 24 hours per day.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program for six out of six sampled residents (Residents 11, 64, 102, 25, 26, and 282) by failing to ensure:
1. Licensed Vocational Nurse 6 (LVN 6) wiped the blood pressure apparatus (instrument for measuring blood pressure) and the glucometer (a small, portable machine that is used to measure how much glucose [a type of sugar] is in the blood) before and after resident use with an antiseptic wipe (pre-moistened towelettes that contain a sanitizing or disinfecting formula that kill or reduce germs) to Residents 11 and 102.
2. The oxygen tubing (a tube used for oxygen delivery) of Resident 64 was labeled with the date it was changed.
3. The Yankauer suction catheter (a suction tool used to remove secretions, such as mucus, from a person's airway) for Resident 25 was labeled with the date when it was opened.
4. The urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) drainage bag for Resident 26 was not touching the floor.
5. The intravenous (IV) tubing tip for Resident 282 was covered with a cap after use.
These deficient practices had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of infection among residents.
Findings:
1.a. A review of Resident 11's admission Record indicated the facility admitted the resident on 7/30/2021, with diagnoses including contact with and suspected exposure to Coronavirus Disease 2019 (COVID-19, a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks), personal history of COVID-19, and diabetes mellitus type 2 (a condition that affects the way the body regulates and uses blood sugar)
A review of Resident 11's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/3/2023, indicated Resident 11 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and had the ability to make self-understood and understand others.
A review of Resident 11's Order Summary Report, dated 5/14/2023, indicated a physician's order for Novolog Flexpen (Insulin Aspart, a short-acting, man-made version of human insulin [a medication lo lower blood sugar]) Subcutaneous (layer of tissue directly under the skin) Solution Pen-Injector 100 unit per milliliter (unit/ml - unit of measurement), inject as per sliding scale (a scale with insulin dosage variations to be administered based on blood sugar levels).
1.b. A review of Resident 102's admission Record indicated the facility admitted the resident on 11/29/2022 and readmitted the resident on 4/11/2023, with diagnoses including proteus mirabilis morganii (an organism causing disease to its host in the urinary tract), type 2 diabetes with foot ulcer (open sores or lesions that will not heal or that return over a long period of time), and sepsis (a potentially life-threatening complication of an infection).
A review of Resident 102's History and Physical (H&P), dated 4/12/2023, indicated Resident 102 had the capacity to understand and make decisions.
A review of Resident 102's MDS, dated [DATE], indicated Resident 102 had moderately impaired cognition and had the ability to make self-understood and understand others.
A review of Resident 102's Order Summary Report, indicated the following physician's orders:
- Enhanced barrier precaution (an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of infection) due to extended spectrum beta-lactamase (ESBL, are enzymes produced by some bacteria that may make them resistant to some antibiotics) colonized (the germ is present on their skin or in a body opening, but they have no signs of illness), date of order: 6/16/2023.
- Finger Stick Blood Sugar (FSBS, an easy way to measure the amount of a certain substances in the blood) every morning and at bedtime. Call MD is BS less than (<) 60 or greater than (>) 400; date of order: 4/13/2023.
- Amlodipine besylate tablet 5 milligrams (mg - unit of measurement).Give 1 tablet by mouth one time a day for hypertension (high blood pressure). Hold (do not administer) for systolic blood pressure (SBP, the blood pressure when the heart is contracting) less than 100; date of order: 10/3/2023.
During an observation and interview on 10/4/2023, at 8:39 a.m., observed LVN 6 take the blood pressure of Resident 102 with a blood pressure apparatus without wiping it with an antiseptic wipe. LVN 6 did not wipe the blood pressure apparatus with an antiseptic wipe after taking the blood pressure of Resident 102. LVN 6 took the blood pressure apparatus to Resident 11 and took the resident's blood pressure. After taking the blood pressure of Resident 11, LVN 6 did not wipe the blood pressure apparatus with an antiseptic wipe. Observed LVN 6 do a blood sugar finger stick with Resident 102 using a glucometer without wiping it with an antiseptic wipe. LVN 6 did not wipe the glucometer with an antiseptic wipe after taking the blood sugar of Resident 102. LVN 6 took the glucometer to Resident 11 and took took the resident's blood sugar. After taking the blood sugar of Resident 11, LVN 6 did not wipe the glucometer with an antiseptic wipe. LVN 6 stated that she should have wiped the blood pressure apparatus and the glucometer before and after patient use to prevent infection. LVN 6 stated the deficient practice had the potential to spread infection among residents.
During an interview on 10/6/2023, at 10:05 a.m., the Director of Staff Development (DSD) stated the facility licensed nurse staff should sanitize care equipment apparatuses (blood pressure apparatus and glucometer) in between resident use to prevent cross contamination.
During an interview on 10/6/2023, at 10:28 a.m., the Director of Nursing (DON) stated the staff should have wiped the equipment before and after use for infection control.
A review of the facility's recent policy and procedures titled, Cleaning and Disinfection of Resident-Care Items and Equipment, last reviewed on 5/2023, indicated reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).
a. Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g., bedpans, urinals).
Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturer's instructions.
2. A review of Resident 64's admission Record indicated the facility admitted the resident on 11/9/2021 and readmitted the resident on 7/7/2023, with diagnoses including chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems), disorders of the lung, and esophagitis (inflammation of the esophagus [a muscular tube that conveys food from the mouth to the stomach]).
A review of Resident 64's H&P, dated 8/28/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 64's MDS, dated [DATE], indicated the resident had intact cognition and had the ability to make self-understood and understand others. The MDS indicated Resident 64 was on oxygen therapy.
A review of Resident 64's Order Summary Report indicated the following physician orders:
- Enhanced barrier precaution; date of order: 7/7/2023.
Oxygen at 2 liters per minute (L/min, a unit of mass flow rate of a gas via nasal cannula (a medical device to provide supplemental oxygen therapy to keep oxygen (O2) saturation (measurement of the amount of oxygen in the bloodstream) above 92 percent (%). Diagnosis (Dx): COPD if needed (PRN); date of order: 7/7/2023.
- Change oxygen tubing on every day shift every Sunday: 7/16/2023.
During an observation on 10/2/2023 at 10 a.m., observed Resident 64's oxygen tubing via nasal cannula not labeled with the date changed.
During an interview on 10/4/2023, at 11:45 a.m., the Infection Preventionist (IP) stated the oxygen tubing should be dated to know when to change the tubing and for infection control because the tubing was only good for one week.
A review of the facility's recent policy and procedure titled Departmental (Respiratory Therapy) - Prevention of Infection, last reviewed on 5/2023, indicated to change the oxygen cannulae and tubing every seven (7) days, or as needed.
3. A review of Resident 25's admission Record indicated the facility admitted the resident on 6/18/2011 and readmitted the resident on 2/23/2020 with diagnoses including gastrostomy (gastrostomy (G-tube - a surgical procedure for inserting a tube through the abdomen wall and into the stomach and used for feeding or drainage), heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs, and dysphagia (difficulty swallowing).
A review of Resident 25's History and Physical dated 9/26/2022, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 25's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/1/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision from staff with eating, total assistance from staff with bathing, and extensive assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During an observation on 10/3/2023 at 8:30 a.m. and 10/4/2023 at 8:00 a.m., observed Resident 25's Yankauer suction catheter packaging opened. The packaging did not indicate the date it was opened.
During a concurrent observation and interview on 10/6/2023 at 9:28 a.m., the Assistant Director of Nursing (ADON) verified the Yankauer suction catheter inserted inside the packaging and did not indicate the date it was opened. The ADON stated the catheter should have been dated when opened and changed every Sunday per facility protocol. The ADON stated the suction catheter was already contaminated and placed the resident at risk for acquiring infection.
During an interview on 10/6/2023 at 10:13 a.m., the Infection Preventionist stated that suction catheters should be dated when opened and changed every week per facility protocol in order to prevent placing Resident 25 at risk for infection.
During an interview on 10/6/2023 at 10:28 a.m., the Director of Nursing (DON) stated the facility did not have a specific policy to address indicating the date on the suction catheter packaging once opened and the frequency of changing the catheters. The DON stated it is the facility practice to change the suction catheters weekly and indicate the date when they were opened for infection control issue and for staff to know when the catheter was last changed.
4. A review of Resident 26's admission Record indicated the facility admitted the resident on 12/8/2022 with diagnoses including urinary tract infection (an infection when bacteria get into the urine and travels up to the bladder, generalized muscle weakness, and metabolic encephalopathy (a condition that occurs when problems with your metabolism cause brain dysfunction).
A review of Resident 26's History and Physical dated 12/10/2022, indicated the resident had the capacity to understand and make decisions.
A review of Resident 26's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/6/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision from staff with eating, total assistance from staff with bathing, and extensive assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a concurrent observation and interview on 10/3/2023 at 9:47 a.m., observed Resident 26's bed in a low position with the urinary catheter drainage bag touching the floor. Certified Nursing Assistant 12 (CNA 12) verified that the drainage bag was touching the floor. CNA 12 stated Resident 26's urinary catheter drainage touching the floor is an infection control issue.
During an interview on 10/3/2023 at 9:47 a.m., Licensed Vocational Nurse 5 (LVN 5) stated Resident 26's urinary catheter drainage bag should not be touching the floor.
During an interview on 10/6/2023 at 9:18 a.m., the Infection Preventionist (IP) stated that the facility practice was to place a basin underneath the urinary catheter drainage bag to prevent the bag from touching the floor because bacteria can travel from the bag to the catheter. The IP stated having the urinary catheter drainage bag touching the floor had the potential to cause infection to the resident. The IP stated that all staff are responsible in ensuring the drainage bags are not touching the floor.
5. A review of Resident 282's admission Record indicated the facility admitted the resident on 9/18/2023 and readmitted on [DATE] with diagnoses including osteomyelitis (inflammation or swelling that occurs in the bone), epilepsy (a condition that affects the brain and causes frequent seizures), and generalized muscle weakness.
A review of Resident 282's History and Physical dated 9/19/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 282's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/25/2023, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision from staff with eating, limited assistance with bed mobility, and extensive assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 282's Order Summary Report indicated the following orders:
1.
Zosyn intravenous (IV)solution reconstituted 3.375 grams (gm - a unit of measurement) with order date 9/18/2023 use 3.375 gm intravenously every eight hours for osteomyelitis until 10/06/2023.
2.
Daptomycin IV solution reconstituted 350 milligrams (mg - a unit of measurement) with order date 9/18/2023 use 350 mg intravenously in the afternoon for osteomyelitis until 10/06/2023.
During a concurrent observation on 10/3/2023 at 8:48 a.m., observed in Resident 282's room, the resident's empty bag of Zosyn and IV tubing hanging on an IV pole. The IV tubing tip was observed without a cap or cover.
During a concurrent interview and record review on 10/3/2023 at 8:51 a.m., the Assistant Director of Nursing (ADON) stated that the IV tubing tip did not have a cap or cover. The ADON stated that after each use, the IV tubing tip should be covered because it had the potential to get contaminated placing the resident at risk for acquiring infection.
During an interview on 10/6/202 on 10/6/2023 at 9:13 a.m., the Infection Preventionist (IP) stated that Resident 282's IV tubing tip should have been covered so any pathogens (any disease-causing agents) would not be able to enter the tubing and cause infection on the resident.
A review of the facility's policy and procedure titled, Infection Prevention and Control Program, last reviewed 5/2023, indicated an Infection Prevention and Control Program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy indicated prevention of infection include instituting measures to avoid complications or dissemination, and educating staff and ensuring that they adhere to proper techniques and procedures.
A review of the facility's policy and procedure titled, Urinary Tract Infections (Catheter Associated), Guidelines for Preventing, last reviewed 5/2023, indicated do not place the drainage bag on the floor as one of the catheter-associated urinary tract infection(CAUTI) prevention strategies adopted and are to be followed by the clinical staff.
A review of the facility's policy and procedure titled, Intravenous Administration of Fluids and Electrolytes, last reviewed 5/2023 indicated that for intermittent therapy, if tubing will be reused, sterile cap should be replaced.
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 maintain an effective pest control program so that th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests (e.g. mosquitoes and flies) when the following occurred:
1. Flying insects were observed inside Resident 50 and Resident 118's room.
Resident 118's bathroom window screen had a hole in it.
2. The conference room bathroom window screen had an opening, not sealed to the window, and multiple mosquitoes were observed on the ceiling and walls.
These deficient practices resulted in Resident 50 unable to eat her dinner due to exposure to flies and Resident 118 feeling annoyed due to the pests. These also placed the potential for residents and staff to be exposed to mosquito bites.
Findings:
a. A review of Resident 50's admission Record indicated the resident was admitted to the facility originally on 10/13/2016 and was readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (also called ischemic stroke which occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting the left non-dominant side.
A review of Resident 50's Minimum Data Set (MDS - an assessment and care screening tool), dated 9/29/2023, indicated the resident was cognitively intact (able to understand and make decisions).
A review of Resident 118's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other abnormalities of gait (manner of walking) and mobility, generalized muscle weakness, and hypertension (high blood pressure).
A review of Resident 118's MDS, dated [DATE], indicated Resident 118 was cognitively intact.
During a concurrent observation and interview with Resident 50, on 10/4/2023, at 10:25 a.m., inside Resident 50's room, observed insects flying around the resident's face. Resident 50 stated, These bugs are annoying and it's hard to eat in my room.
During a concurrent observation and interview with Resident 118, on 10/5/2023, at 10:14 a.m., inside Resident 118's room, a fly was flying around Resident 118's bed. Resident 118 stated the coming from his bathroom. Resident 118 further stated the presence of flies in the room did not feel homelike.
During a concurrent observation and interview with the Maintenance Supervisor (MS), on 10/5/2023, at 10:34 a.m., inside Resident 118's bathroom, observed the bathroom window screen with a hole and an insect was flying around the bathroom. The MS confirmed the presence of the flying insect and stated the insects are flies were coming from the outside. The MS stated it is possible the insects were coming through the hole in the window screen.
During a concurrent observation and interview with Resident 50, on 10/6/2023, at 12:15 p.m., inside Resident 50's room, the resident stated there were fruit flies in her room and she was not able to eat her dinner the night before. Resident 50 stated she bought an insect catcher for her room and it had caught some flies. Observed a device attached to a power cable emitting blue light. The device contained an adhesive paper with multiple fruit flies stuck to the paper.
b. During an observation, on 10/5/2023, at 10:00 a.m., inside the conference room bathroom, observed multiple mosquitoes on the ceiling and walls and a gap between the window screen and the window screen holder.
During a concurrent observation and interview with the Maintenance Supervisor (MS), on 10/5/2023, at 10:37 a.m., observed the conference room bathroom with mosquitoes on the ceiling and walls and a gap between the window screen and window screen holder. The MS stated the mosquitoes could be entering through the gap in the window screen.
A review of the facility's policy and procedure (P&P) titled, Pest Control, reviewed in 5/2023, indicated the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. The P&P indicated windows are screened at all times. The P&P further indicated maintenance services assist, when appropriate and necessary, in providing pest control services.
A review of the facility's contracted Pest Control Service's Service Report, dated 10/3/2023, indicated Additionally, unless otherwise expressly agreed upon in writing, any recommendations that are given regarding sanitation &/or physical improvements (clutter removal, patching of holes, cutting back of trees, the fixing of leaky plumbage, etc) are recommendations only.
Sept 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 4) was free of any sig...
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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 11 sampled residents (Resident 4) was free of any significant medications errors when Resident 4 was ordered Percocet (a type of pain medication containing oxycodone [an opioid pain medication used to treat moderate to severe pain] and acetaminophen [a pain medication used to treat minor aches and pain]) 5-325 milligrams (mg – a unit of measure) two tablets every four hours as needed for severe to worst pain and was administered Percocet 10-325 mg two tablets.
This deficient practice had the potential for Resident 4 to experience signs and symptoms related to opioid overdose (a life-threatening event that includes symptoms including shallow breathing, confusion, lessened alertness, and loss of consciousness). There was also a delay in Resident 4's administration of the next scheduled pain medication.
Findings:
A review of Resident 4 ' s admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (also known as a stroke - disrupted blood flow to the brain due to problems with the blood vessels that supply it), polyneuropathy (nerves outside the brain and spinal cord are damaged and cause a decreased ability to move and feel), and muscle spasms (sudden involuntary muscular contraction or convulsive movement).
A review of Resident 4 ' s History & Physical, dated 9/4/2023, indicated Resident 4 had the capacity to understand and make decisions.
A review of Resident 4 ' s Minimum Data Set (MDS – an assessment and care screening tool), dated 7/6/2023, indicated Resident 4 was cognitively intact (able to learn, remember, and use knowledge). Resident 4 ' s MDS further indicated Resident 4 received opioid medication for seven days during assessment.
A review of Resident 4 ' s Order Summary Report, dated 5/16/2023, indicated Resident 4 was ordered Percocet Tablet 5-325 mg give two tablets by mouth every four hours as needed for severe pain to worst pain, seven to 10 out of 10.
A review of Resident 4 ' s Medication Administration Record (MAR), dated 9/2023, indicated Resident 4 was administered Percocet Tablet 5-325 mg two tablets on 9/12/2023 at 1:19 PM.
A review of Resident 4 ' s Nursing Progress Note, dated 9/12/2023, at 2:08 PM, indicated Resident 4 was given the wrong resident ' s pain medication and was placed on monitoring for respiratory distress, vital signs (blood pressure [measurement of the pressure of circulating blood against the walls of blood vessels], heart rate, temperature, respiration rate), and changes in condition.
A review of Resident 4 ' s Nursing Progress Note, dated 9/12/2023, at 2:12 PM, indicated Resident 4 received a higher dose of pain medication and had a medication error.
A review of Resident 4 ' s Care Plan, dated 9/12/2023, indicated a focus on a medication error and interventions including monitoring for respiratory distress, vital signs, and change in condition.
A review of Resident 4 ' s Orders – Administration Note, dated 9/12/223, at 7:13 PM, indicated the physician gave the okay to administer Percocet tablet 5-325 mg two tablets following the medication error from 9/12/2023 7 AM to 3 PM shift.
A review of Resident 4 ' s Medication Administration Record (MAR), dated 9/2023, indicated Resident 4 was administered Percocet Tablet 5-325 mg two tablets on 9/12/2023 at 7:13 PM.
A review of Resident 4 ' s Narcotic and Hypnotic Record, dated 9/11/2023 to 9/14/2023, indicated Resident 4 ' s Percocet 5-325 mg tablet count. The narcotic and hypnotic record indicated the following:
- Amount 15, time 1:17 PM was struck out
- Amount 16, date 9/12/2023, time 1:17 PM was struck out
- Amount 17, date 9/12/2023, time 1:21 PM was struck out
- Amount 18, date 9/12/2023, time 1:21 PM was struck out
- Amount 48, changed to 18, time 7:13 PM
- Amount 47, time 7:13 PM
During an interview with Resident 4, on 9/27/2023, at 12:05 PM, Resident 4 stated on 9/12/2023, at around 1:30 PM, they received their pain medication. Resident 4 stated on 9/12/2023, at around 3 PM, they were informed by Licensed Vocational Nurse (LVN) 2 that they received the wrong dose of Percocet. Resident 4 stated they received two tablets of Percocet 10-325 mg instead of two tablets of Percocet 5-325 mg. Resident 4 stated they were not in distress and their vital signs were normal after the incident. Resident 4 stated around 5:30 PM, their pain level was starting to rise and they requested for their pain medication. Resident 4 stated LVN 5 and Registered Nurse (RN) 1 informed them Resident 4 was on monitoring and were unable to give them their medication until they follow up with the physician. Resident 4 stated they did not receive their pain medication until around 7 PM. Resident 4 stated because they received the wrong medications at around 1:30 PM, it delayed their pain medications from being administered on time.
During an interview with RN 1, on 9/27/2023, at 2:10 PM, RN 1 stated on 9/12/2023, during the 7 AM to 3 PM shift, Resident 4 had a medication error. RN 1 stated Resident 4 ' s medication error was that they received double the dose of their Percocet. RN 1 stated Resident 4 ' s normal dose of Percocet is 5-325 mg one or two tablets depending on their pain level. RN 1 stated Resident 4 ' s medications were dispensed from a Percocet 10-325 mg pack. RN 1 stated on 9/12/2023, at around 5:00 PM to 6:00 PM, Resident 4 was requesting for their pain medication. RN 1 stated they informed Resident 4 that they would need to notify the physician to see if it was okay for Resident 4 to receive their medication. RN 1 stated on 9/12/2023, between 6:30 PM and 6:50 PM, Resident 4 ' s physician notified RN 1 that it was okay to give Resident 4 their medication. RN 1 stated because of the medication error, there was a delay in Resident 4 ' s pain management.
During an interview with LVN 2, on 9/27/2023, at 2:30 PM, LVN 2 stated on 9/12/2023, Resident 4 came to them requesting for their Percocet. LVN 2 stated around the same time Resident 4 was requesting for their Percocet, Resident 10 was requesting for their Percocet. LVN 2 stated Resident 4 ' s Percocet was dispensed as 5-325 mg tablets. LVN 2 stated Resident 10 ' s Percocet was dispensed as 10-325 mg tablets. LVN 2 stated they dispensed Resident 10 ' s Percocet 10-325 mg tablets and administered it to Resident 4. LVN 2 stated Resident 4 received twice the amount of Percocet ordered. LVN 2 stated the medication error caused a delay with Resident 4 ' s pain medication administration.
A review of Resident 10 ' s Narcotic and Hypnotic Record, dated between 9/9/2023 to 9/16/2023, indicated the following:
- Amount 17, date 9/12/2023 time 1:49 PM, wasted
- Amount 18, date 9/12/2023, time 1:49 PM, wasted
During an interview with the Director of Nursing (DON), on 9/27/2023, at 3:28 PM, the DON stated on 9/12/2023, LVN 2 came to the DON office and informed them Resident 4 was given an extra dose of Percocet. The DON stated Resident 4 was ordered Percocet 5-325 mg one to two tablets depending on Resident 4 ' s level of pain. The DON stated Resident 4 was administered two Percocet 10-325 mg. The DON stated LVN 5 and RN 1 had to wait for Resident 4 ' s physician to respond with the approval to resume Resident 4 ' s pain medication. The DON stated the medication error caused a delay in Resident 4 ' s care.
A review of the facility ' s policy and procedure (P&P) titled, Administering Medications, revised 4/2019, indicated medications are administered in a safe and timely manner, and as prescribed. The P&P indicated medications are administered in accordance with prescriber orders, including any required time frame. The P&P indicated medication errors are documented, reported, and reviewed by the quality assurance and performance improvement (QAPI) committee to inform process changes and or the need for additional staff training. The P&P further indicated the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.
Sept 2023
5 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical and mental abuse (deliberate aggressive or violent behavior with the intention to cause harm by one resident to another) inflicted by Resident 2. On 9/16/2023 at 9 a.m. while Resident 1 was sitting on his bed, one of his three roommates (the room was a four-bed room occupied by Residents 1, 2, 4, and 5), Resident 2, approached Resident 1 propelling himself in the wheelchair, took the metal footrest from his wheelchair with the right hand, stood by Resident 1 and tried hitting Resident 1 with the metal footrest. Resident 1 reacted by holding Resident 2's right arm (which was holding the footrest) and avoiding being injured by the metal footrest but then, Resident 2 hit Resident 1 several times with his left hand. During the incident, Resident 1 was screaming for help. At the time of the incident, Certified Nursing Assistant 4 (CNA 4) and CNA 5, were inside the room by Resident 4, and did not intervene immediately. Licensed Vocational Nurse 1 (LVN 1), who was close to Resident 1's room, heard the screaming, went inside the room, and removed the footrest from Resident 2.
As a result, Resident 1 was fearful for his life, felt intimidated, and had trouble sleeping the night of the incident worried that Resident 2 would return to harm him. In addition, Resident 1 sustained two skin tears (wounds that happens when the skin layers separate) to the left forearm (by the wrist) and the left hand between the thumb and the index finger.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 11/9/2021 with diagnoses including gastrostomy tube (GT, a surgical procedure to insert a soft tube through the abdomen and into the stomach for food and medication), dysphagia (difficulty in swallowing), and chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems).
A review of Resident 1's History and Physical exam, dated 8/28/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/15/2023, indicated Resident 1's was able to remember and make decisions and needed supervision for all activities of daily living (ADLs, such as bed mobility, transfers, walking, dressing, eating, toilet use and personal hygiene).
A review of Resident 2's admission Record indicated the facility admitted the resident on 4/18/2023 with diagnoses including Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), and diabetes mellitus (uncontrolled elevated blood sugar).
A review of Resident 2's MDS, dated [DATE], indicated resident had decline in memory and thinking abilities and required extensive assistance from staff for dressing and personal hygiene. Resident 2 used a wheelchair for mobility.
A review of Resident 2's Situation-Background-Assessment-Recommendation (SBAR) Communication Form (a technique that provides a framework for communication between members of the health care team about a resident's condition), dated 9/16/2023 and timed at 9:15 a.m., indicated Resident 2 did not recall the reason for hitting the roommate (Resident 1) but accused him of trying to poison him (Resident 2).
A review of facility's final Investigation Report, dated 9/21/2023, sent to the State Survey Agency (SSA), indicated Resident 2 hit Resident 1 on the left forearm with a metal footrest. CNA 4 saw Resident 2 going to Resident 1's direction and thought Resident 2, who had no history of aggressive behavior, was just confused about his bed. CNA 4 turned to Resident 4 and when heard Resident 1 started yelling that Resident 2 hit him, CNA 4 rushed to separate them, and two other staff to de-escalate (reduce the intensity of a conflict or potentially violent situation) the situation. Resident 2 was moved to a different room,
On 9/23/2023 at 6 a.m., during an observation and concurrent interview of Resident 1, Resident 1 was walking with using a walker with a folding chair. Resident 1 stated that on the day of the incident (9/16/2023) after breakfast he was sitting on his bed when he saw Resident 2 pushing his wheelchair (while sitting on the wheelchair) towards him (Resident 1). Resident 1 stated he told Resident 2 to stop (coming to him) but instead Resident 2 grabbed the metal wheelchair footrest with the right hand, stood up, and tried to hit him with it. Resident 1 stated he grabbed Resident 2's right arm to block him from hitting him but then Resident 2 hit him with his left hand causing him two bleeding cuts on his left arm and hand. Resident 1 stated he turned around to call for help and saw two staff just watching him get beaten up. Resident 1 stated both staff did not help him. Resident 1 stated he was scared and felt intimidated by Resident 2 and despite Resident 2 being moved the same day, he could not sleep that night thinking Resident 2 would come back to harm him. Resident 1 showed the Evaluator his healing skin tears which measured about 1 centimeter (cm - unit of measure) each, one was on his left hand, between the thumb and the index finger and the other on the left forearm by the wrist.
During an interview on 9/23/2023 at 8:52 a.m., LVN 1 stated on 9/16/2023 at 8:50 a.m., she was making rounds when she heard somebody screaming in Residents 1's room. She entered the room and saw Resident 1 sitting on his bed with Resident 2 on top of him trying to hit him with a wheelchair footrest. LVN 1 stated she removed the footrest from Resident 1's hand and separated the residents. LVN 1 stated CNAs 4 and 5 were inside the room. LVN 1 stated CNA 4 was assigned to Resident 4 as a one-to-one sitter (staff assigned to be always with a resident due to safety reasons). LVN 1 stated she paged (through an overhead paging system that broadcasts a message to a building area via overhead speakers) the Registered Nurse (also the Infection Preventionist, IP) to help her do a body check on Resident 1. LVN 1 stated Resident 1 had one skin tear on the left hand and one on the left forearm with minimal bleeding.
On 9/23/2023 at 9:21 a.m., during an interview, CNA 5 stated that on 9/16/2023 after breakfast he was inside the room of Residents 1, 2, 4, and 5 talking to CNA 4 and Resident 4 when he heard a sound of a curtain moving. CNA 5 stated when he turned around, he saw Resident 2 open the privacy curtain of Resident 1 while holding a wheelchair footrest. CNA 5 stated he saw Resident 2 throwing himself on top of Resident 1 trying to hit him with the footrest. CNA 5 stated he grabbed Resident 2's arm to prevent him from hitting Resident 1. CNA 5 stated he was not assigned to any resident in that room.
On 9/23/2023 at 9:37 a.m., during an interview, CNA 4 stated that on 9/16/2023 after the residents' breakfast meal, she was talking to CNA 5 at Resident 4's bed, who was sleeping at that time. CNA 4 stated she heard Resident 1 scream and when she turned around, she saw Resident 2 standing on Resident 1's right side of the bed while holding a wheelchair footrest on his right hand and Resident 1 was pushing Resident 2 away. CNA 4 stated she saw blood in Resident 1's left arm after the two residents were separated by LVN 1.
During an interview on 9/26/2023 at 10:12 a.m., the IP stated on 9/16/2023, she was overhead paged to Resident 1's room at 9 a.m., and when she arrived LVN 1 and CNA 4 were in the room with Resident 1 sitting on his bed and Resident 2 sitting in a wheelchair away from Resident 1. The IP stated she was not aware that CNA 5 was inside the room when the incident happened. The IP stated all residents have the right to be free from abuse.
On 9/26/2023 at 12:20 p.m., during an interview with the Director of Nursing (DON) and concurrent review of facility's abuse policy, titled, Abuse and Neglect-Clinical Protocol, dated 3/2018 and reviewed on 5/2023, the DON defined abuse as willful intent to inflict harm. The DON stated she did not think Resident 2 had a willful intent to hurt Resident 1 due to confusion; therefore, it was not abuse but just a resident-to-resident altercation.
During an interview on 9/26/2023 at 1:13 p.m., the Administrator (ADM) defined abuse as the willful infliction of injury. The ADM stated they reported the incident as abuse as Resident 2 had intent of hitting Resident 1 and acted on doing it.
A review of facility's policy and procedure titled, Abuse and Neglect-Clinical Protocol, dated 3/2018 and reviewed on 5/2023, indicated Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, mental anguish .Willful as defined .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
A review of facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program , reviewed on 5/2023, indicated, Residents have the right to be free from abuse, neglect misappropriation of resident property and exploitation. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to, b. Other residents .
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
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 its abuse policy by not conducting a thorough investigati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse policy by not conducting a thorough investigation for a resident-to-resident abuse for two of three sampled residents (Resident 1 and Resident 2) when Resident 2 hit Resident 1 with the wheelchair footrest on 9/16/2023.
This deficient practice had the potential to result in unidentified abuse and placed the residents at risk for further abuse.
Findings:
a. A review of Resident 1's admission Record indicated the facility admitted the resident on 11/9/2021 with diagnoses that included gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach for food and medication), dysphagia (difficulty in swallowing) and chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems).
A review of Resident 1's History and Physical, dated 8/28/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/15/2023, indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding). Resident 1 required supervision for activities of daily living (ADL- bed mobility, transfers, walking, dressing, eating, toilet use and personal hygiene). Resident 1 was always continent (have control) of bowel and bladder functions.
A review of Resident 1's Change in Condition (COC- change in residents medical, mental, and level of care) Evaluation, dated 9/16/2023, indicated Resident 2 hit Resident 1 with the wheelchair footrest resulting to a left forearm and left-hand skin tear.
A review of Resident 1's Care Plan Conference Summary, dated 9/22/2023, indicated, Facility Interdisciplinary Team (IDT- a health care team to ensure that various aspects of residents' healthcare needs are integrated, aligned, addressed, and met in a time-efficient manner) meeting was held and based on facility's investigation, Resident 2 hit Resident 1 with the wheelchair footrest and Resident 1 sustained a left forearm skin tear and left hand skin tear.
b. A review of Resident 2's admission Record indicated the facility admitted the resident on 4/18/2023 with diagnoses that included Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), rhabdomyolysis (when damaged muscle tissue releases its proteins into the blood that can damage the heart and kidneys and cause permanent disability or even death), and diabetes mellitus (uncontrolled elevated blood sugar).
A review of Resident 2's MDS, dated [DATE], indicated the resident's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 2 was totally dependent on staff for bed mobility, dressing, and toilet use and required extensive assistance from staff for dressing and personal hygiene. Resident 2 was always incontinent (unable to control) of bowel and bladder functions.
A review of Resident 2's Situation Background Assessment and Recommendation (SBAR-form that provides communication between members of the health care team) Communication Form, dated 9/16/2023, indicated Resident 2 hit Resident 1 with the wheelchair footrest. The SBAR indicated Resident 2 was accusing Resident 1 of trying to poison him.
c. A review of Resident 4's admission Record indicated the facility admitted the resident on 1/30/2023 with diagnoses including hemiplegia ( loss of strength or almost complete weakness in the half side of the body), hemiparesis ( decreased strength in half side of the body), hypertension (uncontrolled elevated blood pressure) and dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities).
A review of Resident 4's History and Physical, dated 3/9/2023, indicated the resident can make needs known but cannot make medical decisions.
A review of facility's Investigation Report (IR), dated 9/21/2023, indicated the incident happened on 9/16/2023 at 9 a.m., inside Resident 1 and Resident 2's room. The IR indicated Licensed Vocational Nurse 1 (LVN 1) reported Resident 2 hit Resident 1 with a wheelchair footrest. The IR indicated that Certified Nursing Assistant 4 (CNA 4) who was inside the room at the time of the incident saw Resident 2 went quietly to Resident 1's area. CNA 4 thought that Resident 2 was just confused on the location of his bed. CNA 4 heard Resident 1 yelling that Resident 2 hit him. CNA 4 rushed to separate them.
During an interview on 9/23/2023 at 8:52 a.m., LVN 1 stated that on 9/16/2023 at 8:50 a.m., she heard someone screaming in Resident 1 and Resident 2's room. LVN 1 stated when she went inside the room, she saw Resident 1 sitting on the bed with Resident 2 on top of him trying to hit him with a wheelchair footrest. LVN 1 stated CNA 4 and CNA 5 were inside the residents' room when the incident happened.
During an interview on 9/23/2023 at 9:21 a.m., CNA 5 stated that on 9/16/2023, he was inside Resident 1 and Resident 2's room talking to CNA 4 when he heard the curtain moving. CNA 5 stated when he turned around, he saw Resident 2 standing, holding on to the wheelchair and the other hand holding a wheelchair footrest. CNA 5 stated he saw Resident 2 threw himself on top of Resident 1's bed and tried to hit Resident 1with the wheelchair footrest.
During an interview on 9/23/2023 at 9: 37 a.m., CNA 4 stated on 9/16/2023 she was assigned as a one-on-one sitter (staff assigned to one resident to prevent a fall or redirect a resident from engaging in a harmful act) to Resident 4 who was sleeping at that time. CNA 4 stated she heard Resident 1 scream and when she turned around, she saw Resident 2 standing on Resident 1's right side of the bed holding a wheelchair footrest on his right hand and Resident 1 pushing Resident 2 away from him. CNA 4 stated she saw blood in Resident 1's left arm after the two residents were separated.
During an interview on 9/26/2023 at 1:13 p.m., the Administrator (ADM) provided two written statements from CNA 4 and LVN 1. The ADM stated he was not aware that CNA 5 was in the room when the resident-to-resident altercation happen on 9/16/2023. The ADM stated they do not have a written statement from CNA 5. The ADM stated it is the facility's policy to conduct a thorough investigation.
A review of facility's Witness Statement for Investigation, dated 9/16/2023, documented by CNA 4, indicated CNA 4 and CNA 5 were inside the room when Resident 1 was yelling because Resident 2 was hitting Resident 1 with wheelchair footrest.
A review of facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating , dated 9/2022 and reviewed on 5/2023, indicated, All allegations are thoroughly investigated.
7. The individual conducting the investigation as a minimum:
e. interviews any witnesses to the incident.
h. interviews staff members (on all shift) who had contact with the resident during the period of the alleged incident.
l. documents the investigation completely and thoroughly.
8. The following guideline are used when conducting interviews:
d. witness statement is obtained in writing, signed, and dated. The witness may write his her statement, or the investigator may obtain a statement.
11. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the Administrator.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to develop a comprehensive care plan for the use of the anticoagulant (blood thinner, medication used to prevent blood clot) Lovenox for one o...
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Based on interview and record review, the facility failed to develop a comprehensive care plan for the use of the anticoagulant (blood thinner, medication used to prevent blood clot) Lovenox for one of three sampled residents (Resident 3). Resident 3 was injected Lovenox every 12 hours as ordered on 7/4/2023, but there was no care plan, from 7/4/2023 to 9/26/2023, to monitor for side effects including bleeding and bruising.
This deficient practice placed the resident at risk for experiencing unidentified side effects.
Findings:
A review of Resident 3's admission Record indicated the facility admitted the resident on 7/3/2023 with diagnoses including metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood leading to personality changes), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and hypertension (uncontrolled elevated blood pressure).
A review of Resident 3's History and Physical exam, dated 7/13/2023, indicated the resident could not make his own decisions but communicate needs.
A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/10/2023, indicated the resident's cognitive (mental action or processes of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. Resident 3 required extensive assistance from staff for all activities of daily living (ADLs such as bed mobility, transfer, walking, dressing, toilet use, and personal hygiene). The MDS indicated the resident was taking an anticoagulant medication.
A review of Resident 3's Physician Order dated 7/4/2023 indicated to inject Lovenox 100 milligram per milliliter (mg/ml- unit of measure) 0.9 ml subcutaneously (beneath, or under, all the layers of the skin) every 12 hours for deep vein thrombosis (DVT- formation of one or more blood clots in one of the body's large veins, most commonly in the lower legs) prophylaxis (prevention).
A review of Resident 3's Medication Administration Record (MAR) for 7/4/2023 to 8/3/2023, indicated Resident 3 received Lovenox as ordered every 12 hours.
On 9/26/2023 at 11 a.m., during an interview with the MDS Nurse (MDSN) and concurrent review of Resident 3's plan of care, MDSN stated there was no care plan developed for Resident 3's use of Lovenox. The MDSN stated the resident should have a care plan for the use of an anticoagulant for nursing staff to monitor the Resident 3 for bleeding and bruising daily.
During an interview on 9/26/2023 at 12:20 p.m., the Director of Nursing (DON) stated residents on anticoagulant should have a care plan for its use because the medication's side effects need to be monitored.
A review of facility's policy and procedure, titled Comprehensive Person-Centered Care Plans dated 12/2016 and reviewed on 5/2023, indicated The comprehensive, person-centered care plans will:
b. Describe the services that are to be furnished to attain r maintain the resident's highest practicable physical, mental, and psychological well-being.
c. Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.
g. Incorporate identified problem areas.
h. Incorporate risk factors associated with identified problems.
k. Reflect treatment goals, timetables, and objectives in measurable outcomes.
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 F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure the resident's drug regimen is free from unnecessary drugs when used without adequate monitoring for one of four sampled residents (...
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Based on interview and record review, the facility failed to ensure the resident's drug regimen is free from unnecessary drugs when used without adequate monitoring for one of four sampled residents (Resident 3). Resident 3 was receiving the anticoagulant (blood thinner, medication used to prevent blood clot) Lovenox every 12 hours as ordered on 7/4/2023, but the nursing staff were not monitoring Resident 3 for side effects including bleeding and bruising from 7/4/2023 to 9/26/2023.
This deficient practice placed the resident at risk for experiencing unidentified side effects.
Findings:
A review of Resident 3's admission Record (Face Sheet) indicated the facility admitted the resident on 7/3/2023 with diagnoses including metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood leading to personality changes), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and hypertension (uncontrolled elevated blood pressure).
A review of Resident 3's History and Physical exam, dated 7/13/2023, indicated the resident could not make his own decisions but communicate needs.
A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/10/2023, indicated the resident's cognitive (mental action or processes of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. Resident 3 required extensive assistance from staff for all activities of daily living (ADLs such as bed mobility, transfer, walking, dressing, toilet use, and personal hygiene). The MDS indicated the resident was taking an anticoagulant medication.
A review of Resident 3's Physician Order dated 7/4/2023 indicated to inject Lovenox 100 milligram per milliliter (mg/ml- unit of measure) 0.9 ml subcutaneously (beneath, or under, all the layers of the skin) every 12 hours for deep vein thrombosis (DVT- formation of one or more blood clots in one of the body's large veins, most commonly in the lower legs) prophylaxis (prevention).
A review of Resident 3's Medication Administration Record (MAR) for 7/4/2023 to 8/3/2023, indicated Resident 3 received Lovenox as ordered every 12 hours.
On 9/26/2023 at 10:12 a.m., during an interview with Registered Nurse 2 (RN 2) and concurrent review of Resident 3's clinical record, RN 2 stated there was no documentation Resident 3 was monitored daily for for bleeding and bruising daily.
During an interview on 9/26/2023 at 12:20 p.m., the Director of Nursing (DON) stated residents on anticoagulant should be monitored for the medication's side effects. The DON stated the facility did not have policy on the use of anticoagulants.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by failing to ensure that one of three kitchen staff (Dishwasher 1 [DW 1...
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Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by failing to ensure that one of three kitchen staff (Dishwasher 1 [DW 1]) was wearing a hair restraint (cover) while inside the kitchen.
This deficient practice had the potential to compromise the integrity of food and placed the residents at risk for foodborne illnesses (illness caused by the ingestion of contaminated food or beverage).
Findings:
During a concurrent observation and interview on 9/23/2023 at 7:35 a.m. with Certified Nursing Assistant 1 (CNA 1), by the kitchen door. Observed Dishwasher 1 (DW 1) standing inside the kitchen with no hair restraint (cover). CNA 1 confirmed DW 1 was not wearing a hair restraint.
During an interview on 9/23/2023 at 7:36 a.m., DW 1 stated she forgot to put on a hair restraint.
During an interview on 9/23/2023 at 7:40 a.m., Registered Nurse 1 (RN 1) stated kitchen staff should wear a hair restraint, so it does not contaminate (any substance that is present in food and can potentially cause harm) the food.
During an interview on 9/26/2023 at 12:08 p.m., the Dietary Supervisor (DS) stated everybody who works and enters the kitchen needs to wear a hair restraint or hair cover to prevent hair from getting into food and utensils causing food contamination.
During an interview on 9/26/2023 at 12:20 p.m., the Director of Nursing (DON) stated staff inside the kitchen should wear a hair restraint to prevent food contamination.
A review of facility's policy and procedure titled, Food Preparation and Service, dated 4/2019 and reviewed on 5/2023, indicated Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint) so that hair does not contact food.
Sept 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 observation, interview and record review, the licensed nursing staff failed to follow professional standards of nursing...
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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 follow professional standards of nursing practice for one of two sampled residents (Resident 1) by failing to notify the physician when Resident 1's systolic blood pressure (measures the pressure in the arteries when the heart beats) was greater than 180 millimeters of mercury (mmHg-measurement of pressure).
This deficient practice had the potential to place Resident 1 at risk for complications of high blood pressure.
Findings:
A review of the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted the resident on 6/20/2023 with diagnoses that included paranoid schizophrenia (a subtype of this condition because paranoia commonly happens with schizophrenia. Paranoia is a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), generalized anxiety disorder (an overwhelming, ongoing fear of being watched and judged by others), pain in left foot, hypertension (high blood pressure), and opioid dependence.
A review of Resident 1 ' s History and Physical (H & P) dated 4/6/2023, indicated the resident has the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS- a standardized resident assessment and care screening tool) dated 8/15/2023, indicated the resident ' s cognition is moderately impaired. The MDS indicated the resident can understand others and be understood. The resident required supervision with bed mobility, transfer, locomotion on and off unit, eating, toilet use, personal hygiene and required limited assistance from one staff with dressing and bathing.
A review of the physician ' s order dated 4/27/2023, indicated an order to administer Lotensin (medication to treat high blood pressure) oral tablet 20 mg one time a day for high blood pressure. Hold for SBP lower than 110 mmHg.
A review of another physician ' s order dated 9/2/2023, indicated an order to monitor blood pressure every shift. Call MD if SBP greater than 180 mmHg.
A review of the Medication Administration Record (MAR) for 9/2023, indicated that on 9/18/2023, at 9 am Resident 1 ' s blood pressure was 185/101 mmHg.
A review of the Nursing Progress Note dated 9/18/2023 at 8:17 am indicated Resident 1 ' s BP was 185/101 mmHg and Resident 1 refused BP to be retaken. There was no documentation indicating that Licensed Vocational Nurse 3 (LVN 3) notified the physician regarding the resident ' s high blood pressure.
On 9/22/2023, at 12:15 pm, during a concurrent interview and record review with LVN 3, reviewed the resident's medical records including physician orders and nursing progress notes. LVN 3 stated that on 9/18/23 at 8:17 am, she took Resident 1's blood pressure while Resident 1 was sitting in bed. LVN 3 stated the resident's BP was elevated at 185/101 mmHg and the resident refused to have her BP retaken. There was no documentation indicating that LVN 3 notified the physician regarding Resident 1's BP of 185/101. LVN 3 stated she should have notified the physician when the resident's SBP was greater than 180 mmHg
On 9/22/2023, at 2:10 pm, during a concurrent interview and record review, reviewed physician orders with the DON. The DON stated that there is an order to notify the physician if the Resident 1's SBP is greater than 180 mmHg and that the nurse should have notified the physician when the resident's SBP was180 mmHg on 9/18/2023 at 9 am.
A review of Resident 1's care plan created on 4/04/2023, indicated that Resident 1 has high blood pressure. The interventions included to give anti-hypertensive medications as ordered; to monitor for side effect such as orthostatic hypotension and increased heart rate and effectiveness. The goal is to keep Resident 1 free of complications related to elevated blood pressure.
A review of another care plan created on 9/01/2023, indicated Resident 1 has altered cardiovascular status related to elevated blood pressure of SBP>150 mmHg and DBP> 90 mmHg. Resident 1 is on Lotensin (medication used to lower blood pressure) PO (by mouth), Lasix (medication used to treat swelling of the ankles, feet, legs or even the brain or lungs) PO. The goal is to keep Resident 1 remain free of complications related to elevated BP. The interventions included to monitor BP Q shift. Call MD if SBP>180 mmHg.
A review of the facility ' s Policy dated February 2014, titled Guidelines for Notifying Physicians of Clinical Problems indicated these guidelines are to help ensure that medical care problems are communicated to the medical staff in a timely manner, efficient, and effective manner and all significant changes in resident status are assessed and documented in the medical record. The charge nurse or supervisor should contact the attending physician at any time if they feel a clinical situation requires immediate discussion and managemen
Sept 2023
7 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident ' s right to be free from neglect ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident ' s right to be free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of three sampled residents (Resident 1) by:
1. Failing to monitor Resident 1 ' s whereabouts and failing to provide supervision to Resident 1 who was at risk for wandering (going about from place to place) and high risk for falls.
2. Failing to ensure Resident 1 ' s wander guard bracelet (a device designed to activate alarms when a resident gets closer to entry and exit points) activated the wander guard alarm or system when Resident 1, in his wheelchair, exited the exit door near Station 1 while wheeling himself going outside the building to the smoking patio.
3. Failing to ensure staff were monitoring and checking Resident 1 ' s wander guard bracelet was working properly per manufacturer ' s guidelines.
4. Failing to ensure the door alarms at Station 1 exit door activated when Resident 1 exited using that door going to the smoking patio.
5. Failing to ensure the surveillance cameras were monitored when Resident 1 exited by the exit door at Station 1 while wheeling himself going outside the building to the smoking patio in the pouring rain.
As a result, Resident 1 exited to the smoking patio on 8/20/2023 at 6:38 p.m. unnoticed and sustained an unwitnessed fall and was exposed to the rain for 13 minutes until the staff assisted Resident 1 back inside the facility at 6:51 p.m. This happened during a hurricane named [NAME] that was expected to cause extreme rain and flooding. This placed Resident 1 at high risk for hypothermia (a medical emergency that occurs when your body loses heat faster that it can produce heat, causing a dangerously low body temperature, which may lead to cardiac [referring to the heart] and respiratory [referring to the lungs] failure and eventually to death) from staying wet and cold for a prolonged period. Also, based on the reasonable person concept (refers to a tool to assist the survey team ' s assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Resident 1 ' s severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills and medical condition, an individual subjected to neglect, may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself).
On 9/4/2023 at 6:39 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation. The Administrator and Registered Nurse 2 (RN 2) were notified of the IJ from the failure to ensure Resident 1 was free from neglect.
On 9/7/2023 at 11:23 a.m., the IJ was removed in the presence of the Administrator and Director of Nursing (DON), while onsite, after verifying through observation, interview, and record review the implementation of the facility ' s submitted and accepted IJ Removal Plan which included the following summarized actions:
1. Resident 1 ' s whereabouts were monitored by licensed nurses every shift. Resident 1 was continuously being placed in a highly visible area such as in front of the nurse station, activity room and dining room for close observation. The assigned certified nursing assistant (CNA) to continue frequent visual monitoring of the resident every two hours during shift.
2. Maintenance Supervisor checked all the facility ' s entry/exit doors including emergency exits on 9/1/2023. All stop alarms on emergency entry/exit doors were functioning well.
3. All facility ' s entry and exit doors to include emergency exits will be monitored by the maintenance staff/designee daily for proper function. In case an entry/exit door alarm is not working, a facility staff will be assigned to monitor until the malfunctioning (not working) entry/exit door is fixed.
4. Continue to ensure wander guards are in place and functioning on high-risk residents.
5. DON conducted a review of all residents on wander guards on 9/4/2023 to ensure placement and functional wander guards.
6. Director of Staff Development (DSD) started providing in-service to all staff on 9/5/2023 regarding the facility ' s policy and procedures on the following:
a. Wander Guard Monitoring for Placement and Functioning based on Manufacturer ' s Guidelines
b. Resident Monitoring for Safety and Supervision
c. Resident Abuse, and Neglect
d. Accident, Hazards, and Safety
7. The licensed nurse to check wander guard placement and functionality (whether it is working) every shift and document result. The date of placement will also be documented including the date of the replacement.
8. The Licensed Nurse to conduct nursing huddles to CNAs and charge nurses at the beginning of each shift to discuss residents at risk for wandering (to go about from place to place usually without a plan or definite purpose) including residents with wander guard devices.
9. Residents at risk for wandering will be checked by CNAs, restorative nursing assistants (RNAs), and licensed nurses during routine bedside care, scheduled medication administration, room rounds, and mealtime.
10. Activity staff to observe residents at risk for wandering if they are attending group activities.
11. The charge nurse on duty will ensure direct supervision/monitoring high risk for wandering residents is being conducted by assigned staff/CNA and endorsed to the next shift.
12. The entry/exit doors including emergency entry/exit doors and patio entry/exit door monitoring logs will be collected by the DSD/designee and will be reported during daily stand-up meetings. The RN supervisor/charge nurse/designee on duty during weekends will continue the process and report any discrepancy to the DON/Administrator/designee.
13. The Administrator/designee will review the exit door alarm check log daily for 30 days, the wander guard information log, and follow up immediately if with any negative findings. Any follow-up needed will be reported to the monthly Quality Assurance and Performance Improvement Committee for additional recommendation if there are residents who are high risk for wandering in the facility. The QAPI Committee will provide written recommendations to the Administrator. The Administrator will review such recommendations and act accordingly.
Cross Reference with F689.
Findings:
A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 1/30/2023 and readmitted on [DATE] with diagnoses including hemiplegia (paralysis that affects only one side of your body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it that deprives brain cells of oxygen and vital nutrients which can cause parts of the brain to die off) affecting right dominant (in control) side , encephalopathy (alteration of mental status due to medications or toxic chemicals), muscle weakness, other abnormalities of gait (walking) and mobility, repeated falls, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), unspecified severity, with other behavioral disturbance , and personal history of other mental and behavioral disorders.
A review of Resident 1 ' s care plan, dated 5/9/2023, indicated resident was at risk for fall, injury, and wandering with history of wanting to go home. Interventions included to apply wander guard in the ankle and in wheelchair due to resident episodes of removing wander guard on wrist and to apply wander guard to monitor any attempts of getting out of the facility. Other interventions included to monitor and document for wander guard placement and function, monitor resident any attempts to wander/go outside unattended and unknown to staff, and tally with hashmark.
A review of the physician ' s order of Resident 1, dated 5/24/2023 at 5:47 p.m., indicated an order to apply wander guard to Resident 1 to monitor any attempts of getting out of the facility. The physician ' s order indicated to monitor Resident 1 for wander guard ' s placement and function by documenting Y for Yes or N for No.
A review of Resident 1 ' s Minimum Data Set (MDS - standardized assessment and care planning tool), dated 8/4/2023, indicated Resident 1 ' s cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 1 required extensive assistance with two-person physical assistance with bed mobility and transfer and required extensive assistance with one person assistance with locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair), locomotion off unit (how resident moves to and returns from off-unit locations like areas set aside for dining, activities, or treatment. If facility has only one floor, how resident moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair), dressing, toilet use, and personal hygiene.
A review of Resident 1 ' s Wandering Assessment form, dated 8/18/2023 at 4:33 p.m., indicated Resident 1 was a high risk for wandering.
A review of Resident 1 ' s Fall Risk Assessment form, dated 8/18/2023 at 4:38 p.m., indicated Resident 1 was considered a high risk for potential falls.
A review of Resident 1 ' s nursing progress note, dated 8/20/2023 at 8:22 p.m., indicated that on 8/20/2023 at 7:07 p.m. Resident 1 had an unwitnessed fall outside in the smoking patio and that Resident 1 was attempting to roll wheelchair but got stuck and tipped over. The nursing progress note indicated Resident 1 stated he was cold.
On 8/26/2023 at 12:08 p.m., during an interview, Certified Nursing Assistant 6 (CNA 6) stated Resident 1 was a one-to-one (needing an assigned sitter). CNA 6 stated she was informed by another resident (name not given) that Resident 1 was on the floor in the smoking patio. CNA 6 stated that she went to check the smoking patio from Station 1 ' s exit doors and found Resident 1 lying on the ground still in his wheelchair. CNA 6 stated that it was raining, and Resident 1 fell with his wheelchair and was lying in a puddle of water. CNA 6 further stated that when she (CNA 6) exited the doors of Station 1 to the smoking patio, there were no door alarms that were heard.
On 8/26/2023 at 12:26 p.m., during an interview, RN 1 stated that Resident 1 is a high risk for fall and a high risk for wandering. RN 1 stated that typically Resident 1 had an assigned one-to-one sitter but sometimes did not have anyone assigned as a one-to-one sitter because of no available staff to be a sitter. RN 1 stated that on 8/20/2023, Resident 1 did not have anyone assigned to him as a one-to-one sitter for the 3 p.m. to 11 p.m. shift.
On 8/26/2023 at 12:28 p.m., during an interview, the DON stated that Resident 1 had an unwitnessed fall on 8/20/2023. The DON stated that Resident 1 was a high risk for fall and a high risk for wandering. As part of a nursing intervention, the facility provides a one-to-one sitter but not all the time. When asked why not all the time, the DON answered because the one-to-one sitter was not a physician ' s order for Resident 1.
On 8/27/2023 at 3:20 p.m., during an interview, CNA 7 stated that Resident 1 needed a one-to-one sitter to monitor him for wandering. CNA 7 stated that Resident 1 requires a one-to-one sitter to ensure his safety. CNA 7 further stated that Resident 1 needed more supervision because Resident 1 was an extreme fall risk. CNA 7 stated that he did not document Resident 1 ' s whereabouts during his 3 p.m. to 11 p.m. shift on 8/20/2023.
On 8/27/2023 at 3:33 p.m., during an interview, CNA 8 stated that Resident 1 wandered around the facility. CNA 8 stated that facility staff were aware that Resident 1 was a fall risk and high risk for wandering. CNA 8 further stated that Resident 1 did not have a one-to-one sitter. CNA 8 stated she did not document Resident 1 ' s whereabouts during her 3 p.m. to 11 p.m. shift on 8/20/2023.
On 8/27/2023 at 3:50 p.m., during an interview, Licensed Vocational Nurse 9 (LVN 9) stated that he was the assigned charge nurse for Resident 1 on 8/20/2023. When asked how the functionality of the wander guard bracelet was checked, LVN 9 stated that he did not check for the functionality of the wander guard bracelet on Resident 1.
On 8/27/2023 at 4:00 p.m., during an interview, Housekeeping/Maintenance Staff (HMS) stated that exit doors in Station 1 had two alarms: the wander guard alarm and the red door alarms. The red door alarms should always be in the on position and no staff should be exiting through these doors. When the red alarm door is opened, the alarm will activate. The only way it will turn off is with a key held by housekeeping staff, maintenance staff, or licensed nurses. HMS stated that he did not know who was responsible to ensure that the red door alarms were armed (turned on).
On 8/27/2023 at 4:15 p.m., during an interview, Licensed Vocational Nurse 10 (LVN 10) stated that on 8/20/2023 that she (LVN 10) saw Resident 1 wheeling himself in his wheelchair around the facility. On 8/20/2023 another resident (name not given) informed LVN 10 that there was a resident that fell in the smoking patio. LVN 10 stated that together with CNA 6 they went to the smoking patio through the exit at Station 1 and found Resident 1 on the ground, in the pouring rain, with his wheelchair tipped over to his left side. LVN 10 stated that they found Resident 1 in a puddle of water, however, his head was not in the water. When asked if LVN 10 heard any alarms at that time, LVN 10 stated she did not hear any alarms because if she did, she would remember because the alarms ' noise is ear piercing.
On 8/27/2023 at 4:50 p.m., during an interview, LVN 11 stated that Resident 1 currently has a wander guard bracelet. When asked how the functionality of the wander guard bracelet is checked, LVN 11 stated that she wheels Resident 1 near the door and if the alarm sounds Resident 1 ' s wander guard bracelet is functional. When asked how the functionality of the wander guard bracelet is checked if Resident 1 was in bed the whole day, LVN 11 stated she did not think of that and would not know how to check for functionality. LVN 11 further stated that she is not aware of the facility ' s policy on how to check for functionality of the wander guard bracelet.
On 8/27/2023 at 6:11 p.m., during a concurrent observation and interview with the Assistant Director of Nursing (ADON), observed Certified Nursing Assistant 8 (CNA 8) wheeling Resident 1 (who was wearing the wander guard bracelet on his left ankle) in his wheelchair through Station 1 ' s exit that was facing the smoking patio. Observed Resident 1 outside in the smoking patio. Observed the wander guard system alarm did not sound an alarm. The ADON stated that the alarm did not sound and that the wander guard had malfunctioned. The ADON stated that the wander guard alarm should have started alarming prior to the resident exiting the door.
On 9/3/2023 at 1:37 p.m., during a concurrent interview and review of the facility provided video footage taken from outside the building capturing the moment Resident 1, in his wheelchair, wheeling himself and exited the exit door near Station 1 going to the smoking patio on 8/20/2023, RN 2 stated the following events:
1. 5:38 p.m. (time adjusted considering daylight saving time to reflect the actual time of the event) - It was raining, and Resident 1 was wheeling himself towards the black gate (in the smoking patio).
2. 5:40 p.m. - Resident 1 was at the gate.
3. 5:41 p.m. - Resident 1 was wheeling self. It is difficult to tell what he is doing.
4. 5:42 p.m. - Resident 1 fell to the ground on his left side still sitting in his wheelchair (wheelchair also fell with Resident 1). Resident 1 was moving and looked like he is trying to get up but was unable to. It was still raining.
5. 5:49 p.m. - Facility staff came out.
6. 5:50 p.m. - Four staff went out to help Resident 1. It is difficult to distinguish who the staff are.
On 9/3/2023 at 2:15 p.m., during an interview, the Administrator stated that based on the video footage that the facility reviewed, it showed that Resident 1 was wheeling himself through station 1 ' s exit door and Resident 1 was able to push through the door and was able to lead himself to the smoking patio unsupervised, where he did have an unwitnessed fall. The Administrator stated he did not have access and autonomy (the ability of the person to make his or her own decisions) to pull past video footages because that needs to be requested from the Information Technology (IT) department at the corporate level. The Administrator stated the reason of having camera footages is for security purposes and recording incidents and accidents. The Administrator stated he has no one monitoring the cameras.
On 9/3/2023 at 2:25 p.m., during an interview, Maintenance Staff 1 (MS 1) stated that the wander guard alarm system is checked by MS 1 weekly. MS 1 stated the wander guard alarm system is checked for functionality by a testing devise that his department is using. MS 1 stated that he points the testing devise at the exit door where the wander guard system alarms are located, and it should alarm. When it alarms, MS 1 reset the wander guard system alarm with a code. MS 1 stated that currently the wander guard system alarm at Station 1 by the smoking patio is still not functioning and is waiting for a replacement part to be delivered.
On 9/4/2023 at 1:25 p.m., during an interview, the Administrator stated that the red door alarm is the backup alarm for the exit doors. The Administrator stated that in the absence of the wander guard system the red door alarm is the fail-safe (guaranteed to work) alarm. The Administrator further stated that moving forward he will ensure that all exit doors that have the door alarms will be double- and triple-checked to ensure residents ' safety.
On 9/4/2023 at 1:52 p.m., during an interview, RN 1 stated that Resident 1 ' s fall incident was avoidable. RN 1 stated that the facility did its best to supervise Resident 1 however the facility did not have enough staff to watch Resident 1 with a one-to-one sitter, which he needed.
On 9/4/2023 at 4:02 p.m., during an interview, the Administrator stated Resident 1 ' s unwitnessed fall incident in the smoking patio was an avoidable incident. The Administrator stated that the incident would have been avoidable if the wander guard system was working. The ADM stated that he believed that if the wander guard alarm went off and sounded it would have alerted someone to where Resident 1 was at the time.
On 9/4/2023 at 4:35 p.m., during an interview, the DON stated that Resident 1 ' s unwitnessed fall incident in the smoking patio could have been avoided if there was proper supervision of Resident 1. The DON stated that someone should have known that Resident 1 was missing from the nurse ' s station. The DON stated that staff are supposed to supervise Resident 1 but, on that day, 8/20/2023, the facility had a lot of staff call outs because of the storm.
A review of the facility provided policy titled, Abuse Prevention Program, revised 12/2016, indicated a policy statement indicating, Our residents have the right to be free from . neglect Develop and implement policies and procedures to aid our facility in preventing . neglect
A review of the facility provided policy titled, Abuse and Neglect - Clinical Protocol, revised 3/2018, indicated under Treatment and Management that, The facility management and staff will institute measures to address the needs of residents and minimize the possibility of . neglect.
A review of the facility provided policy titled, Tab Alarms, Bed Alarms, Wanderguard System, undated, indicated, 6. After each application of the . wanderguard bracelet in place, a licensed nursing staff/appropriate designee will conduct a safety check to verify alarm device used is in proper working condition including proper function and placement to facility used alarm system per manufacturer instruction a) Documentation of the . wanderguard bracelet alarm proper function and placement checks will be made to the resident ' s clinical record on each unit and each shift daily and/or as directed per MD (medical doctor) order. b) Licensed Nursing Staff/Designee will be assigned to conduct safety check every shift on resident . wanderguard alarm device if repair or replacement needed c) Nursing Aide/staff to be made aware of resident on alarm system device use each shift for close supervision and will notify licensed nurse if identify . wanderguard bracelet alarm without proper function/placement immediately.
A review of the facility provided policy titled, Closed-Circuit TVs, revised 4/2017, indicated, Our facility uses closed-circuit TVs in common areas of the facility (hallways, dining rooms, employee work areas, outside areas, etc.) to monitor the safety and well-being of our staff and residents.
A review of the facility provided policy titled, Safety and Supervision of Residents, revised 7/2017, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities When accident hazards are identifies, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of hazards and develop strategies to mitigate or remove the hazards to the extent possible. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accidents hazards and try to prevent accident. Under individualized, resident-centered approach to safety, it indicated that individualized resident-centered approach to safety addresses safety and accident hazards for individual residents The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devises.
Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Document interventions. Monitoring the effectiveness of interventions shall include the following: a. Ensuring the interventions are implemented correctly and consistently; b. Evaluating the effectiveness of interventions; c. Modifying or replacing interventions as needed; and d. Evaluating the effectiveness of new or revised interventions.
A review of the facility provided manual on WanderGuard® ID SystemUser and Installation Manual, indicated Bracelet Testing:
1. Hold the Universal Tester within 1 foot from the bracelet, pointing the tester towards the bracelet. If the tester is not pointed towards the bracelet while testing a false bracelet test failure may occur;
2. Press and release the BRACLET button one time. The light above the button will flash and the test will search for a bracelet. You will notice the display will show scrolling animation until it detects the bracelet and then displays the test results. If the tester does not immediately detect the bracelet, it will continue to search for 10 seconds, then time out;
3. When the bracelet test is good, the tester display will show the bracelet ' s programmed 3-digit ID# and the bracelet test light will also blink green 4 times. The t3-digit ID # range is 000 to 899; 4. If a bracelet is in end of service mode, the tester display will show the bracelet ' s 3-digit ID # and the bracelet test light will stay steady red. This indicates the bracelet must be replaced immediately; 5. If a bracelet tests as bad, or is out of range of the tester, the display will show a dashed line across the center and the bracelet test light will stay steady red. Treat the result as indication of a non-functioning bracelet until proven otherwise. A second test should be conducted to confirm the state of the bracelet. Please refer to the Universal Tester User Manual for complete detailed instructions if you have any questions on the bracelet test procedure. Under DOOR Testing:
The Universal Tester is designed to be used with the WanderGuard® ID System. The Universal Tester will also test WanderGuard® E, D, and 202 door modules but without the audio and visual feedback from the System Status Display or an audible chirp while testing for bracelet coverage. The Universal Tester will transmit a simulated bracelet signal. A normally functioning WanderGuard® ID System monitored door will recognize and react to this signal as if it were transmitted from a signaling device bracelet. The tester itself will not display the results of the test. Rather, the test results will be evident at the monitored door. The Primary Antenna and the System Status Display (SSD) will provide visual and audio feedback confirming normal operation. Under Detection Verification:
1. Make sure the door is closed or the Passive Infrared Sensor (PIR) is not detecting motion;
2. Hold the tester approximately six inches to the side of the door opening on the side opposite the monitor antenna at approximately door handle height. The tester should be held in a vertical (up-and-down) position for this test. If the WanderGuard® is monitoring a hallway or double doors, place the tester mid-way between the two antennas;
3. Press and hold the DOOR button on the Universal Tester. The amber light above the button will turn on and its display will show moving bars when the tester is transmitting. The Universal Tester will shut itself off after about 30 seconds of continuous button pressing. Releasing and again pressing the button will restart the test;
4. If the tester signal is detected, the primary antenna will begin chirping and the antenna light will flash orange. The System Status Display (SSD)will display DOOR TEST;
5. If the antenna does not chirp and the SSD displays BRACELET DETECTED instead, there is not sufficient signal to identify the tester ID (the system is still able to detect that a bracelet signal is present and will alarm if the door is opened or motion is sensed by a PIR).
Moving the tester closer toward the antenna until the antenna begins to chirp will give an indication of where the ID detection begins;
6. The antenna not chirping and the SSD not indicating a bracelet has been detected may be an indication of:
1) The system is non-operational,
2) The system has reduced range or
3) The tester is not functioning or has shut itself off.;
7. In the case of no system response, move the tester to within 12 inches of an antenna and press and hold the DOOR button on the tester. If a response is now obtained, the system's range has been reduced and you should proceed to the troubleshooting section to try to resolve the problem; 8. If no response is obtained at 12 inches from the antenna, try the tester at a different WanderGuard® ID monitor to see if the tester is functioning. If the tester is working at a different monitor, then the door monitor is not working properly. Refer to the Troubleshooting section for more instructions. Alternatively, an active bracelet can be used at the non-responsive location to see if it is functional.
The Medical Records personnel was not able to provide the facility ' s policy and procedure regarding red door alarms.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), wh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed as high risk for wandering (going about from place to place), with a wander-guard (a device designed to activate alarms when a resident gets closer to entries and exit points) in place as ordered by the physician was kept free from accidents and hazards by:
1. Failing to monitor and provide supervision to Resident 1 who was at risk for wandering and high risk for falls.
2. Failing to ensure Resident 1 ' s wander guard bracelet (a device designed to activate alarms when a resident gets closer to entry and exit points) activated the wander guard alarm or system when Resident 1, in his wheelchair, exited the exit door near Station 1 while wheeling himself going outside the building to the smoking patio.
3. Failing to ensure staff were monitoring and checking Resident 1 ' s wander guard bracelet was working properly per manufacturer ' s guidelines.
4. Failing to ensure the door alarms at Station 1 exit door activated when Resident 1 exited using that door going to the smoking patio.
5. Failing to ensure the surveillance cameras were monitored when Resident 1 exited by the exit door at Station 1 while wheeling himself going outside the building to the smoking patio in the pouring rain.
As a result, Resident 1 exited to the smoking patio on 8/20/2023 at 6:38 p.m. unnoticed and sustained an unwitnessed fall and was exposed to the rain for 13 minutes until the staff assisted Resident 1 back inside the facility at 6:51 p.m. This happened during a hurricane named [NAME] that was expected to cause extreme rain and flooding. This placed Resident 1 at high risk for hypothermia (a medical emergency that occurs when your body loses heat faster that it can produce heat, causing a dangerously low body temperature, which may lead to cardiac [referring to the heart] and respiratory [referring to the lungs] failure and eventually to death) from staying wet and cold for a prolonged period. Also, based on the reasonable person concept (refers to a tool to assist the survey team ' s assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Resident 1 ' s severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills and medical condition, an individual subjected to neglect, may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself).
On 9/4/2023 at 6:39 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR §483.25(d) Accidents. The Administrator and Registered Nurse 2 (RN 2) were notified of the IJ from the failure to ensure staff provided the necessary care and services to prevent Resident 1 to wander outside the facility to the smoking patio without supervision and sustained an unwitnessed fall.
On 9/7/2023 at 11:23 a.m., the IJ was removed in the presence of the Administrator and Director of Nursing (DON), while onsite, after verifying through observation, interview, and record review the implementation of the facility ' s submitted and accepted IJ Removal Plan which included the following summarized actions:
1. Resident 1 ' s whereabouts were monitored by licensed nurses every shift. Resident 1 was continuously being placed in a highly visible area such as in front of the nurse station, activity room and dining room for close observation. The assigned certified nursing assistant (CNA) to continue frequent visual monitoring of the resident every two hours during shift.
2. Maintenance Supervisor checked all the facility ' s entry/exit doors including emergency exits on 9/1/2023. All stop alarms on emergency entry/exit doors were functioning well.
3. All facility ' s entry and exit doors to include emergency exits will be monitored by the maintenance staff/designee daily for proper function. In case an entry/exit door alarm is not working, a facility staff will be assigned to monitor until the malfunctioning (not working) entry/exit door is fixed.
4. Continue to ensure wander guards are in place and functioning on high-risk residents.
5. DON conducted a review of all residents on wander guards on 9/4/2023 to ensure placement and functional wander guards.
6. Director of Staff Development (DSD) started providing in-service to all staff on 9/5/2023 regarding the facility ' s policy and procedures on the following:
a. Wander Guard Monitoring for Placement and Functioning based on Manufacturer ' s Guidelines
b. Resident Monitoring for Safety and Supervision
c. Resident Abuse, and Neglect
d. Accident, Hazards, and Safety
7. The licensed nurse to check wander guard placement and functionality (whether it is working) every shift and document result. The date of placement will also be documented including the date of the replacement.
8. The Licensed Nurse to conduct nursing huddles to CNAs and charge nurses at the beginning of each shift to discuss residents at risk for wandering (to go about from place to place usually without a plan or definite purpose) including residents with wander guard devices.
9. Residents at risk for wandering will be checked by CNAs, restorative Nursing assistants (RNAs), and licensed nurses during routine bedside care, scheduled medication administration, room rounds, and mealtime.
10. Activity staff to observe residents at risk for wandering if they are attending group activities.
11. The charge nurse on duty will ensure direct supervision/monitoring high risk for wandering residents is being conducted by assigned staff/CNA and endorsed to the next shift.
12. The entry/exit doors including emergency entry/exit doors and patio entry/exit door monitoring logs will be collected by the DSD/designee and will be reported during daily stand-up meetings. The RN supervisor/charge nurse/designee on duty during weekends will continue the process and report any discrepancy to the DON/Administrator/designee.
13. The Administrator/designee will review the exit door alarm check log daily for 30 days, the wander guard information log, and follow up immediately if with any negative findings.
Any follow-up needed will be reported to the monthly Quality Assurance and Performance Improvement Committee for additional recommendation if there are residents who are high risk for wandering in the facility. The QAPI Committee will provide written recommendations to the Administrator. The Administrator will review such recommendations and act accordingly.
Cross Reference with F600.
Findings:
A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 1/30/2023 and readmitted on [DATE] with diagnoses including hemiplegia (paralysis that affects only one side of your body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it that deprives brain cells of oxygen and vital nutrients which can cause parts of the brain to die off) affecting right dominant (in control) side , encephalopathy (alteration of mental status due to medications or toxic chemicals), muscle weakness, other abnormalities of gait (walking) and mobility, repeated falls, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), unspecified severity, with other behavioral disturbance, and personal history of other mental and behavioral disorders.
A review of Resident 1 ' s care plan, dated 5/9/2023, indicated resident was at risk for fall, injury, and wandering with history of wanting to go home. Interventions included to apply wander guard on the ankle and in wheelchair due to resident episodes of removing wander guard on wrist and to apply wander guard to monitor any attempts of getting out of the facility. Other interventions included to monitor and document for wander guard placement and function, monitor resident any attempts to wander/go outside unattended and unknown to staff, and tally with hashmark (tally marks).
A review of the physician ' s order of Resident 1, dated 5/24/2023 at 5:47 p.m., indicated an order to apply wander guard to Resident 1 to monitor any attempts of getting out of the facility. The physician ' s order indicated to monitor Resident 1 for wander guard ' s placement and function by documenting Y for Yes or N for No.
A review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 8/4/2023, indicated Resident 1 ' s cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 1 required extensive assistance with two-person physical assistance with bed mobility and transfer and required extensive assistance with one person assistance with locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair), locomotion off unit (how resident moves to and returns from off-unit locations like areas set aside for dining, activities, or treatment. If facility has only one floor, how resident moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair), dressing, toilet use, and personal hygiene.
A review of Resident 1 ' s Wandering Assessment form, dated 8/18/2023 at 4:33 p.m., indicated Resident 1 was a high risk for wandering.
A review of Resident 1 ' s Fall Risk Assessment form, dated 8/18/2023 at 4:38 p.m., indicated Resident 1 was considered a high risk for potential falls.
A review of Resident 1 ' s nursing progress note, dated 8/20/2023 at 8:22 p.m., indicated that on 8/20/2023 at 7:07 p.m. Resident 1 had an unwitnessed fall outside in the smoking patio and that Resident 1 was attempting to roll wheelchair but got stuck and tipped over. The nursing progress note indicated Resident 1 stated he was cold.
On 8/26/2023 at 12:08 p.m., during an interview, Certified Nursing Assistant 6 (CNA 6) stated Resident 1 was a one-to-one (needing an assigned sitter). CNA 6 stated she was informed by another resident (name not given) that Resident 1 was on the floor in the smoking patio. CNA 6 stated that she went to check the smoking patio from Station 1 ' s exit doors and found Resident 1 lying on the ground still in his wheelchair. CNA 6 stated that it was raining, and Resident 1 fell with his wheelchair and was lying in a puddle of water. CNA 6 further stated that when she (CNA 6) exited the doors of Station 1 to the smoking patio, there were no door alarms that were heard.
On 8/26/2023 at 12:26 p.m., during an interview, RN 1 stated that Resident 1 is a high risk for fall and a high risk for wandering. RN 1 stated that typically Resident 1 had an assigned one-to-one sitter but sometimes did not have anyone assigned as a one-to-one sitter because of staffing. RN 1 stated that on 8/20/2023, Resident 1 did not have anyone assigned to him as a one-to-one sitter for the 3 p.m. to 11 p.m. shift.
On 8/26/2023 at 12:28 p.m., during an interview, the DON stated that Resident 1 had an unwitnessed fall on 8/20/2023. The DON stated that Resident 1 was a high risk for fall and a high risk for wandering. As part of a nursing intervention, the facility provides a one-to-one sitter but not all the time. When asked why not all the time, the DON answered because the one-to-one sitter was not a physician ' s order for Resident 1.
On 8/27/2023 at 3:20 p.m., during an interview, CNA 7 stated that Resident 1 needed a one-to-one sitter to monitor him for wandering. CNA 7 stated that Resident 1 requires a one-to-one sitter to ensure his safety. CNA 7 further stated that Resident 1 needed more supervision because Resident 1 was an extreme fall risk. CNA 7 stated that he did not document Resident 1 ' s whereabouts during his 3 p.m. to 11 p.m. shift.
On 8/27/2023 at 3:33 p.m., during an interview, CNA 8 stated that Resident 1 wandered around the facility. CNA 8 stated that facility staff were aware that Resident 1 was a fall risk and high risk for wandering. CNA 8 further stated that Resident 1 did not have a one-to-one sitter. CNA 8 stated she did not document Resident 1 ' s whereabouts during her 3 p.m. to 11 p.m. shift.
On 8/27/2023 at 3:50 p.m., during an interview, LVN 9 stated that he was the assigned charge nurse for Resident 1 on 8/20/2023. When asked how the functionality of the wander guard bracelet was checked, LVN 9 stated that he did not check for the functionality of the wander guard bracelet on Resident 1.
On 8/27/2023 at 4:00 p.m., during an interview, Housekeeping/Maintenance Staff (HMS) stated that exit doors in Station 1 had two alarms: the wander guard alarm and the red door alarms. The red door alarms should always be in the on position and no staff should be exiting through these doors. When the red alarm door is opened, the alarm will activate. The only way it will turn off is with a key held by housekeeping staff, maintenance staff, or licensed nurses. HMS stated that he did not know who was responsible to ensure that the red door alarms were armed (turned on).
On 8/27/2023 at 4:15 p.m., during an interview, Licensed Vocational Nurse 10 (LVN 10) stated that on 8/20/2023 that she (LVN 10) saw Resident 1 wheeling himself around the facility. On 8/20/2023 another resident (name not given) informed LVN 10 that there was a resident that fell in the smoking patio. LVN 10 stated that together with CNA 6 they went to the smoking patio through the exit at Station 1 and found Resident 1 on the ground, in the pouring rain, with his wheelchair tipped over to his left side. LVN 10 stated that they found Resident 1 in a puddle of water, however, his head was not in the water. When asked if LVN 10 heard any alarms at that time, LVN 10 stated she did not hear any alarms because if she did, she would remember because the alarms ' noise is ear piercing.
On 8/27/2023 at 4:50 p.m., during an interview, LVN 11 stated that Resident 1 currently has a wander guard bracelet. When asked how the functionality of the wander guard bracelet is checked, LVN 11 stated that she wheels Resident 1 near the door and if the alarm sounds Resident 1 ' s wander guard bracelet is functional. When asked how the functionality of the wander guard bracelet is checked if Resident 1 was in bed the whole day, LVN 11 stated she did not think of that and would not know how to check for functionality. LVN 11 further stated that she is not aware of the facility ' s policy on how to check for functionality of the wander guard bracelet.
On 8/27/2023 at 6:11 p.m., during a concurrent observation and interview with the Assistant Director of Nursing (ADON), observed Certified Nursing Assistant 8 (CNA 8) wheeling Resident 1 (who was wearing the wander guard bracelet on his left ankle) in his wheelchair through Station 1 ' s exit that was facing the smoking patio. Observed Resident 1 outside in the smoking patio. Observed the wander guard system alarm did not sound an alarm. The ADON stated that the alarm did not sound and that the wander guard had malfunctioned. The ADON stated that the wander guard alarm should have started alarming prior to the resident exiting the door.
On 9/3/2023 at 1:37 p.m., during a concurrent interview and review of the video footage taken from outside the building capturing the moment Resident 1, in his wheelchair, wheeling himself and exited the exit door near Station 1 going to the smoking patio, RN 2 stated the following events:
1. 5:38 p.m. (time adjusted considering daylight saving time to reflect the actual time of the event) - It was raining, and Resident 1 was wheeling himself towards the black gate (in the smoking patio).
2. 5:40 p.m. - Resident 1 was at the gate.
3. 5:41 p.m. - Resident 1 was wheeling self. It is difficult to tell what he is doing.
4. 5:42 p.m. - Resident 1 fell to the ground on his left side still sitting in his wheelchair (wheelchair also fell with Resident 1). Resident 1 was moving and looked like he is trying to get up but was unable to. It was still raining.
5. 5:49 p.m. - Facility staff came out.
6. 5:50 p.m. - Four staff went out to help Resident 1. It is difficult to distinguish who the staff are.
On 9/3/2023 at 2:15 p.m., during an interview, the Administrator stated that based on the video footage that the facility reviewed, it showed that Resident 1 was wheeling himself through station 1 ' s exit door and Resident 1 was able to push through the door and was able to lead himself to the smoking patio unsupervised, where he did have an unwitnessed fall. The Administrator stated he did not have access and autonomy (the ability of the person to make his or her own decisions) to pull past video footages because that needs to be requested from the Information Technology (IT) department at the corporate level. The Administrator stated the reason of having camera footages is for security purposes and recording incidents and accidents. The Administrator stated he has no one monitoring the cameras.
On 9/3/2023 at 2:25 p.m., during an interview, Maintenance Staff 1 (MS 1) stated that the wander guard alarm system is checked by MS 1 weekly. MS 1 stated the wander guard alarm system is checked for functionality by a testing devise that his department using. MS 1 stated that he points the testing device at the exit door where the wander guard system alarms are located, and it should alarm. When it alarms, MS 1 reset the wander guard system alarm with a code. MS 1 stated that currently the wander guard system alarm at Station 1 by the smoking patio is still not functioning and is waiting for a replacement part to be delivered.
On 9/4/2023 at 1:25 p.m., during an interview, the Administrator stated that the red door alarm is the backup alarm for the exit doors. The Administrator stated that in the absence of the wander guard system the red door alarm is the fail-safe (guaranteed to work) alarm. The Administrator further stated that moving forward he will ensure that all exit doors that have the door alarms will be double- and triple-checked to ensure residents ' safety.
On 9/4/2023 at 1:52 p.m., during an interview, RN 1 stated that Resident 1 ' s fall incident was avoidable. RN 1 stated that the facility did its best to supervise Resident 1 however the facility did not have enough staff to watch Resident 1 with a one-to-one sitter, which he needed.
On 9/4/2023 at 4:02 p.m., during an interview, the Administrator stated Resident 1 ' s unwitnessed fall incident in the smoking patio was an avoidable incident. The Administrator stated that the incident would have been avoidable if the wander guard system was working. The Administrator stated that he believed that if the wander guard alarm went off and sounded it would have alerted someone to where Resident 1 was at the time.
On 9/4/2023 at 4:35 p.m., during an interview, the DON stated that Resident 1 ' s unwitnessed fall incident in the smoking patio could have been avoided if there was proper supervision of Resident 1. The DON stated that someone should have known that Resident 1 was missing from the nurse ' s station. The DON stated that staff are supposed to supervise Resident 1 but, on that day, 8/20/2023, the facility had a lot of staff call outs because of the storm.
A review of the facility provided policy titled, Safety and Supervision of Residents, revised 7/2017, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment.
A review of the facility provided policy titled, Wander Guard System, undated, indicated it is the policy of this facility to provide residents who are at risk for wandering, eloping (running away) and/or exit-seeking a safe environment and allow them to maintain their highest practicable label of well-being. Under Procedure:
1. Social Services and/or Nursing will assess for wandering, exit-seeking, and/or elopement behaviors on admission, quarterly, annually, and as needed;
2. Licensed nurses to check placement and function of the Wander guard every shift. Licensed nurses to use device tester and/or take resident to an exit door. A blinking green light means the device is working. If it is not working, the device will be replaced immediately;
6. Licensed Nurse or designee to write the date and application of the Wander guard on the Medication Administration Record (MAR); 7. Maintenance or designee to test the functionality of the Wander guard system (door) monthly; 8. Licensed Nurse to Initial MAR every shift for placement and functionality; 9. Resident with Wander guards will be documented and added in the elopement log each time.
A review of the facility provided policy titled, Tab Alarms, Bed Alarms, Wanderguard System, undated, indicated, 6. After each application of the . wanderguard bracelet in place, a licensed nursing staff/appropriate designee will conduct a safety check to verify alarm device used is in proper working condition including proper function and placement to facility used alarm system per manufacturer instruction
a) Documentation of the . wanderguard bracelet alarm proper function and placement checks will be made to the resident ' s clinical record on each unit and each shift daily and/or as directed per MD (medical doctor) order.
b) Licensed Nursing Staff/Designee will be assigned to conduct safety check every shift on resident . wanderguard alarm device if repair or replacement needed
c) Nursing Aide/staff to be made aware of resident on alarm system device use each shift for close supervision and will notify licensed nurse if identify . wanderguard bracelet alarm without proper function/placement immediately.
A review of the facility provided policy titled, Closed-Circuit TVs, revised 4/2017, indicated, Our facility uses closed-circuit TVs in common areas of the facility (hallways, dining rooms, employee work areas, outside areas, etc.) to monitor the safety and well-being of our staff and residents.
During a review of the facility provided manual on WanderGuard® ID SystemUser and Installation Manual, indicated Bracelet Testing:
1. Hold the Universal Tester within 1 foot from the bracelet, pointing the tester towards the bracelet. If the tester is not pointed towards the bracelet while testing a false bracelet test failure may occur;
2. Press and release the BRACLET button one time. The light above the button will flash and the test will search for a bracelet. You will notice the display will show scrolling animation until it detects the bracelet and then displays the test results. If the tester does not immediately detect the bracelet, it will continue to search for 10 seconds, then time out;
3. When the bracelet test is good, the tester display will show the bracelet ' s programmed 3-digit ID# and the bracelet test light will also blink green 4 times. The t3-digit ID # range is 000 to 899;
4. If a bracelet is in end of service mode, the tester display will show the bracelet ' s 3-digit ID # and the bracelet test light will stay steady red. This indicates the bracelet must be replaced immediately;
5. If a bracelet tests as bad, or is out of range of the tester, the display will show a dashed line across the center and the bracelet test light will stay steady red. Treat the result as indication of a non-functioning bracelet until proven otherwise. A second test should be conducted to confirm the state of the bracelet. Please refer to the Universal Tester User Manual for complete detailed instructions if you have any questions on the bracelet test procedure. Under DOOR Testing:
The Universal Tester is designed to be used with the WanderGuard® ID System. The Universal Tester will also test WanderGuard® E, D, and 202 door modules but without the audio and visual feedback from the System Status Display or an audible chirp while testing for bracelet coverage. The Universal Tester will transmit a simulated bracelet signal. A normally functioning WanderGuard® ID System monitored door will recognize and react to this signal as if it were transmitted from a signaling device bracelet. The tester itself will not display the results of the test. Rather, the test results will be evident at the monitored door. The Primary Antenna and the System Status Display (SSD) will provide visual and audio feedback confirming normal operation. Under Detection Verification:
1. Make sure the door is closed or the Passive Infrared Sensor (PIR) is not detecting motion;
2. Hold the tester approximately six inches to the side of the door opening on the side opposite the monitor antenna at approximately door handle height. The tester should be held in a vertical (up-and-down) position for this test. If the WanderGuard® is monitoring a hallway or double doors, place the tester mid-way between the two antennas;
3. Press and hold the DOOR button on the Universal Tester. The amber light above the button will turn on and its display will show moving bars when the tester is transmitting. The Universal Tester will shut itself off after about 30 seconds of continuous button pressing. Releasing and again pressing the button will restart the test;
4. If the tester signal is detected, the primary antenna will begin chirping and the antenna light will flash orange. The System Status Display (SSD)will display DOOR TEST;
5. If the antenna does not chirp and the SSD displays BRACELET DETECTED instead, there is not sufficient signal to identify the tester ID (the system is still able to detect that a bracelet signal is present and will alarm if the door is opened or motion is sensed by a PIR). Moving the tester closer toward the antenna until the antenna begins to chirp will give an indication of where the ID detection begins;
6. The antenna not chirping and the SSD not indicating a bracelet has been detected may be an indication of:
1) The system is non-operational,
2) The system has reduced range or
3) The tester is not functioning or has shut itself off.;
7. In the case of no system response, move the tester to within 12 inches of an antenna and press and hold the DOOR button on the tester. If a response is now obtained, the system's range has been reduced and you should proceed to the troubleshooting section to try to resolve the problem;
8. If no response is obtained at 12 inches from the antenna, try the tester at a different WanderGuard® ID monitor to see if the tester is functioning. If the tester is working at a different monitor, then the door monitor is not working properly. Refer to the Troubleshooting section for more instructions. Alternatively, an active bracelet can be used at the non-responsive location to see if it is functional.
The Medical Records personnel was not able to provide the facility ' s policy and procedure regarding red door alarms.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call lights were within residents ' reach whil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call lights were within residents ' reach while in bed for two out of three sampled residents (Resident 2 and Resident 3).
This deficient practice had the potential to result in resident falls and residents not being able to summon health care workers for assistance when needed.
Findings:
a. A review of Resident 2 ' s admission Record indicated the facility readmitted the resident on 8/11/2023 with diagnoses that included metabolic encephalopathy (broad term for any brain disease that alters brain function or structure), sepsis (life-threatening complication of an infection), and pneumonia (lung inflammation caused by bacterial or viral infection).
A review of Resident 2 ' s Minimum Data Set (MDS- a standardized assessment and screening tool), dated 7/18/2023, indicated Resident 2 had severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS indicated Resident 3 requires extensive assistance with one-person physical assistance with bed mobility, dressing, toilet use, and personal hygiene.
A review of Resident 2 ' s Care Plan, with an initiation date of 7/1/2023, indicated Resident 2 was high risk for minor injury/major injury related to history of multiple falls in the last nine days, decreased strength and endurance, pain, cognitive deficits, communication deficits, poor safety awareness, unsteady gait, poor balance, muscle weakness, decreased functional range of motion (ROM)/joint limitation, use mobility devices, requires assistance and most activities of daily living (ADLs- such as bed mobility, transfer and toileting) and complex medical diagnosis. The Care Plan indicated an intervention to keep call light and frequently used items within reach.
During a concurrent observation and interview on 8/26/2023 at 11:41 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 2 in bed, with his call light not within reach. Observed Resident 2 ' s call light hanging on top of Resident ' s 2 ' s room light, located above Resident 2 ' s headboard. Observed LVN 1 remove the call light from Resident 2 ' s room light and placed it within Resident 2 ' s reach.
b. A review of Resident 3 ' s admission Record indicated the facility readmitted the resident on 8/14/2023 with diagnoses that included encounter for surgical aftercare following surgery on the nervous system (transmits signals between the brain and the rest of the body, including internal organs), muscle weakness, and seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements [stiffness, twitching or limpness], behaviors, sensations or states of awareness).
A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 severely impaired cognitive skills for daily decision making. The MDS indicated Resident 3 required extensive assistance with bed mobility and is totally dependent with dressing, eating, toilet use, and personal hygiene.
During a concurrent observation and interview on 8/26/2023 at 11:45 a.m., with LVN 1, observed Resident 3 in bed, with his call light not within reach of the resident. Observed the call light on the floor next to Resident 3 bedside. Observed LVN 1 picking up the call light from the floor and placing it next to the resident ' s left hand, within resident ' s reach.
A review of the facility-provided policy and procedure titled, Answering the Call Light, revised 9/2022, indicated the purpose of this procedure is to ensure timely responses to the resident ' s requests and needs. Ensure that the call light is accessible to the resident when in bed.
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 F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 5) was seen by attending physician at least every 60 days while in the facility.
This defici...
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Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 5) was seen by attending physician at least every 60 days while in the facility.
This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment, and services.
Findings:
A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 1/12/2007 with diagnoses that included hemiplegia (mild or partial weakness or loss of strength on one side of the body), epilepsy (repeatedly uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body), dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities) and liver cirrhosis (a condition in which the liver is scarred and permanently damaged).
A review of Resident 5 ' s History and Physical, dated 2/22/2022, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 5 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/5/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 5 required extensive assistance from staff for all activities of daily living (ADL- bed mobility, transfers, walking, dressing, toilet use and personal hygiene).
A review of Resident 5 ' s Physician Visit Progress Note indicated resident was last seen by the attending physician on 4/18/2023.
During a concurrent interview and record review on 9/7/2023 at 10:39 a.m., with the Director of Nursing (DON), Resident 5 ' s Physician Visit Progress note dated 4/18/2023 was reviewed. The DON stated it is close to 5 months since Resident 5 was last seen by his attending physician.
A review of facility ' s policy and procedure titled, Physician Visits, dated 4/2013 and reviewed on 5/2023, indicated, The Attending Physician must make visits in accordance with applicable state and federal regulations.
2. The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident ' s admission, and then at least every sixty (60) days thereafter.
4. After ninety (90) days, if the Attending Physician determines that a resident need not be seen by him/her every thirty (30) days, an alternate schedule of visits maybe established, but not to exceed every sixty (60) days. A Physician Assistant or Nurse Practitioner may make alternate visits after the initial ninety (90) days following admissions, unless restricted by law or regulation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident was assessed by a Registered Nurse (RN) afte...
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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 resident was assessed by a Registered Nurse (RN) after an unwitnessed fall incident that occurred on 8/20/2023 for one of three sampled residents (Resident 1).
This deficient practice had the potential for Resident 1 to receive an inaccurate assessment and can lead to a delay in necessary care, treatment, and services.
Findings:
A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 1/30/2023 and readmitted on [DATE] with diagnoses including hemiplegia (paralysis that affects only one side of your body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it that deprives brain cells of oxygen and vital nutrients which can cause parts of the brain to die off) affecting right dominant (in control) side , encephalopathy (alteration of mental status due to medications or toxic chemicals), muscle weakness, other abnormalities of gait (walking) and mobility, repeated falls, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), unspecified severity, with other behavioral disturbance , and personal history of other mental and behavioral disorders.
A review of Resident 1 ' s Minimum Data Set (MDS – an assessment and care screening tool), dated 8/4/2023, indicated Resident 1 ' s cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was severely impaired. The MDS indicated Resident 1 required extensive assistance with two-person physical assistance with bed mobility and transfer and required extensive assistance with one person assistance with locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair), locomotion off unit (how resident moves to and returns from off-unit locations like areas set aside for dining, activities, or treatment. If facility has only one floor, how resident moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair), dressing, toilet use, and personal hygiene.
A review of Resident 1 ' s Fall Risk Assessment form, dated 8/18/2023 at 4:38 p.m., indicated Resident 1 was considered a high risk for potential falls.
A review of Resident 1 ' s care plan, dated 5/9/2023, indicated resident was at risk for fall, injury, and wandering with history of wanting to go home. Interventions included to apply wander guard in the ankle and in wheelchair due to resident episodes of removing wander guard on wrist and to apply wander guard to monitor any attempts of getting out of the facility. Other interventions included to monitor and document for wander guard placement and function, monitor resident any attempts to wander/go outside unattended and unknown to staff, and tally with hashmark.
A review of Resident 1 ' s Fall Risk Assessment form, dated 8/18/2023 at 4:38 p.m., indicated Resident 1 was considered a high risk for potential falls.
A review of Resident 1 ' s nursing progress note, dated 8/20/2023 at 8:22 p.m., indicated that on 8/20/2023 at 7:07 p.m. Resident 1 had an unwitnessed fall outside in the smoking patio and that Resident 1 was attempting to roll wheelchair but got stuck and tipped over. The nursing progress note indicated Resident 1 stated he was cold.
On 8/27/2023 at 3:45 p.m., during an interview, Licensed Vocational Nurse 9 (LVN 9) stated that on 8/20/2023 he was the assigned to the Resident 1 and after Resident 1 ' s unwitnessed fall, LVN 9 assessed Resident 1.
On 9/4/2023 at 1:08 p.m., during and interview, RN 1 stated that on 8/20/2023 when Resident 1 had an unwitnessed fall RN 1 had clocked out and was ready to go home. RN 1 stated that RN 1 gave a list of things to do after the fall to LVN 9. RN 1 stated that after she gave LVN 9 instructions she left the building. RN 1 stated that she did not assess Resident 1 after Resident 1 ' s fall incident. RN 1 stated that she should have assessed Resident 1 but she had clocked out already. RN 1 further stated that RNs should be assessing residents because it is not in the scope of practice for a LVN to assess residents.
A review of the facility ' s policy and procedure titled, Competency of Nursing Staff, revised 5/2019, indicated all nursing staff must meet the specific competency of their respective licensure and certification requirements defined by State Law.
A review of the facility ' s job description title: Registered Nurse (RN); updated: 9/2020. Position summary: Plans and delivers nursing care to residents in accordance with current company, federal, state, and local standards, guidelines and regulations to ensure that the highest degree of quality care and dignity is maintained at all times. Under Duties and Responsibilities: Performs assessment functions including identification of changes in the resident ' s physical or psychological. Condition; 15. Performs documentation duties as required and in accordance with company charting and documentation policies and procedures and government regulations. Ensure documentation is accurate, timely and descriptive of resident ' s condition, nursing care provided and resident ' s response to care; 21. Completes routine rounds during shift to assess residents; 24. Thoroughly understands facility policies and procedures as well as state and federal regulations and serves as a resource for staff; 28. Ensures adherence to state and federal regulations and company policies and procedures.
A review of the facility ' s job description title: Charge Nurse; updated: 9/2020. Indicated keeps abreast of current federal and state regulations, professional standards, industry best practice and facility policies and procedures.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two of three sampled residents (Resid...
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Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two of three sampled residents (Resident 1 and Resident 4) by failing to document holding the medications despite physician ' s order.
This deficient practice may result in confusion in the care and services rendered to residents and may result in inaccurate information entered into residents ' medical records.
Findings:
a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/30/2023 with diagnoses that included hemiplegia (mild or partial weakness or loss of strength on one side of the body), hemiparesis (severe or complete loss of strength or paralysis on one side of the body), encephalopathy (general term that refers to brain disease, damage, or malfunction), muscle weakness, dementia(impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (uncontrolled elevated blood pressure), and repeated falls.
A review of Resident 1 ' s History and Physical, dated 3/9/2023, indicated the resident can make needs known but cannot make medical decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/4/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required extensive assistance from staff for all activities of daily living (ADL - bed mobility, transfers, dressing, toilet use and personal hygiene). Resident 1 was always incontinent (unable to control) of bowel and bladder functions.
A review of Resident 1 ' s Physician Order, dated 4/9/2023, indicated an order for Lisinopril (medication to treat elevated blood pressure) tablet 20 milligrams (mg- unit of measure), give one tablet by mouth one time a day for hypertension, hold for systolic blood pressure (sbp - pressure in the arteries when the heart beats) less than 100 or heart rate less than 60.
A review of Resident 1 ' s Weights and Vitals Exception, dated 9/4/2023 at 9:15 a.m., indicated resident's blood pressure was 100/48 millimeter mercury (mmHg- unit of measure).
A review of Resident 1 ' s Medication Administration Record (MAR), dated 9/2023, indicated on 9/4/2023 at 9 a.m., Licensed Vocational Nurse 8 (LVN 8) documented lisinopril tablet was given.
A review of Resident 1 ' s Care Plan on hypertension, dated 7/13/2023 and revised on 9/5/2023, indicated an intervention to administer medications as ordered by physician.
During a concurrent interview and record review on 9/5/2023 at 4:42 p.m., with the Assistant Director of Nursing (ADON), Resident 1 ' s physician order dated 4/9/2023 and MAR dated 9/2023 were reviewed. The ADON stated LVN 8 documented lisinopril was given on 9/4/2023 at 9 a.m. for a blood pressure of 100/48 mmHg. The DON stated LVN 8 should have held the medication to prevent hypotension (low blood pressure).
During an interview on 9/6/2023 at 9:45 a.m., LVN 8 stated she held the medication but may have accidentally click the medication as given in MAR. LVN 8 stated she should check the physician order before documenting correctly. LVN 8 stated she should have written in the progress note to explain why it was held. LVN 8 showed the bubble pack of lisinopril with 9.4.2023 dose still in it.
During an interview on 9/7/2023 at 9:23 a.m., the Director of Nursing (DON) stated check mark in MAR indicated medication were given. DON stated LVN 8 should have documented in progress notes explaining why it was held. DON stated nurses should not be careless, they have to documente accurately, read, and follow the physician order.
b. A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 1/30/2022 with diagnoses that included left hip primary osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), repeated falls, and hypertension.
A review of Resident 4 ' s MDS 6/16/2023, indicated resident ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 4 required extensive assistance from staff for ADL- bed mobility, transfers, walking, dressing, toilet use and personal hygiene).
A review of Resident 4 ' s Physician Order, dated 12/17/2021, indicated and order for amlodipine besylate (medication used to treat elevated blood pressure) tablet 10 mg by mouth, give daily for hypertension and hold for sbp less than 110.
A review of Resident 4 ' s MAR, dated 9/2023, indicated amlodipine besylate was given at 9 a.m. on the following dates:
1. 9/1/2032 with bp- 99/59
2. 9/3/2023 with bp- 99/65
A review of Resident 4 ' s Care Plan on hypertension, dated 12/17/2021, indicated an intervention to give medications as ordered.
During an interview on 9/7/2023 at 10:01 a.m., LVN 7 stated she held the amlodipine on 9/1/2023 and 9/3/2023 but unable to make changes in the MAR and forgot to document a progress note explaining why it was held. LVN 7 stated she should document correctly following physician ' s order.
During an interview on 9/7/2023 at 10:39 a.m., the DON stated LVN 7 should have documented in the MAR the option outside of parameter if holding a medication following physician ' s order.
A review of facility ' s policy and procedure titled, Administering Medications, dated 4/2019 and reviewed on 5/2023, indicated, If a drug is withheld, refused, or given at a time other than the schedule time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.
A review of facility ' s policy and procedure titled, Charting and Documentation, reviewed on 5/2023, indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control practices for two of thre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control practices for two of three sampled residents (Resident 1 and Resident 5) by failing to ensure Restorative Nursing Assistant 1 (RNA 1), wore N95 mask (respiratory protective device designed to achieve a very close facial fit) covering her nose and mouth while inside the dining area during a Coronavirus Disease- 2019 (COVID-19, a highly contagious respiratory illness in humans capable of producing severe symptoms) outbreak (a sudden rise in the number of cases of a disease).
This deficient practice had the potential to result in the spread of COVID-19 to staff and residents.
Findings:
a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/30/2023 with diagnoses that included hemiplegia (mild or partial weakness or loss of strength on one side of the body), hemiparesis (severe or complete loss of strength or paralysis on one side of the body), encephalopathy (general term that refers to brain disease, damage, or malfunction), muscle weakness, dementia(impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (uncontrolled elevated blood pressure) and repeated falls.
A review of Resident 1 ' s History and Physical, dated 3/9/2023, indicated the resident can make needs known but cannot make medical decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/4/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required extensive assistance from staff for all activities of daily living (ADL- bed mobility, transfers, dressing, toilet use and personal hygiene). Resident 1 was always incontinent (unable to control) of bowel and bladder functions.
b. A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 1/12/2007 with diagnoses that included hemiplegia, epilepsy (repeatedly uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body), dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities) and liver cirrhosis (a condition in which the liver is scarred and permanently damaged).
A review of Resident 5 ' s History and Physical, dated 2/22/2022, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 5 ' s MDS, dated [DATE], indicated resident ' s cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 5 required extensive assistance from staff for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene.
During an observation on 9/5/2023 at 12:06 p.m., inside the dining room, observed Restorative Nursing Assistant 1 (RNA 1) standing beside Resident 5 and across Resident 1 who were both eating while seated in the wheelchair with N95 mask (respiratory protective device designed to achieve a very close facial fit) hanging on her neck. Observed RNA 1 ' s nose and mouth were visible while talking to another resident on the next table.
During an interview on 9/5/2023 at 12:07 p.m., RNA 1 admitted she removed the top strap of her N95 making her nose and mouth visible while standing beside Resident 5 and across Resident 1 who were both eating with no mask on. RNA 1 stated she should keep her N95 mask because they have COVID-19 residents inside the facility.
During an interview on 9/5/2023 at 12:35 p.m., the Infection Preventionist (IP) stated they had a COVID -19 outbreak and had 10 positive residents and nine staff who tested positive. IP stated staff should wear their mask covering both nose and mouth to prevent the spread of COVID-19 to other residents and staff.
During an interview on 9/7/2023 at 10:39 a.m., the Director of Nursing (DON) stated staff should wear their mask with any resident interaction to prevent the spread of COVID-19.
A review of facility ' s policy and procedure titled, C19 Guidance, dated 8/14/2023, indicated, Although masking requirements ended, it is still recommended that staff wear a well- fitting mask while taking care of and interacting with residents of vulnerable populations.
Sept 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure one of three sampled staff (Payroll Staff [PS]), wore mask (a loose-fitting, disposable device that creates a physical ...
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Based on observation, interview, and record review the facility failed to ensure one of three sampled staff (Payroll Staff [PS]), wore mask (a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment) while seated in front of Dietary Supervisor (DS) inside the payroll room.
This deficient practice had the potential to result in the spread of Coronavirus Disease 2019 (COVID-19- highly contagious respiratory infection that spreads from person to person when an infected person coughs, sneezes or talks) to staff and residents.
Findings:
During a concurrent observation and interview on 8/31/2023 at 3:39 p.m., with Receptionist 2 (RCP 2), in the facility ' s lobby. Observed Payroll Staff (PS) not wearing a mask while talking to Dietary Supervisor (DS). RCP 2 stated all staff should wear a mask while inside the facility because the facility had Coronavirus Disease 2019 (COVID-19- highly contagious respiratory infection that spreads from person to person when an infected person coughs, sneezes or talks) outbreak (increase in the number of cases).
During an interview on 8/31/2023 at 3:41 p.m., PS stated she is aware that the facility has an outbreak of COVID-19 and admitted she was not on a safe distance from DS to remove her mask.
During an interview on 8/31/2023 at 3:48 p.m., the DS stated the PS did not put on her mask after drinking water while she was in the room with her. The DS stated COVID-19 can spread if mask is not worn.
During an interview on 8/31/2023 at 3:55 p.m., Registered Nurse 1 (RN 1) stated all staff should wear a mask while inside the facility especially if talking to somebody less than six feet to prevent the spread of COVID-19 to staff and residents. RN 1 stated they have 11 COVID-19 positive residents and seven positive staff for this outbreak.
During an interview on 8/31/2023 at 4:02 p.m., the Director of Nursing (DON) stated the facility had a COVID -19 outbreak. DON stated they recommend staff to wear an N95 if going to COVID-19 positive residents but if not, mask is still necessary. DON stated staff can remove the mask if they are alone in the office to prevent the spread of infection.
A review of facility ' s COVID-19 Mitigation Plan dated 8/7/2023 indicated All staff will wear a facemask while in the facility for source control.
Aug 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physicians order for one of three sampled residents (Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physicians order for one of three sampled residents (Resident 1) by failing to ensure Toprol XL (medication used to treat high blood pressure, chest pain and abnormal rhythms of the heart) was not administered to the resident when the resident ' s systolic blood pressure (sbp-pressure in the arteries when the heart beats) was below 110.
This deficient practice may potentially lower Resident 1 ' s blood pressure.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses including atherosclerotic heart disease (thickening or hardening of the arteries [blood vessels that supply oxygen rich blood from the heart]), muscle weakness and end stage renal disease (ESRD- a medical condition in which a person's kidneys stops functioning on a permanent basis leading to the need for a regular course of long-term dialysis [treatment that helps your body remove extra fluid and waste products from your blood] or a kidney transplant [surgery to place a healthy kidney from a living or deceased donor into a person whose kidneys no longer function] to maintain life).
A review of Resident 1 ' s History and Physical dated [DATE] indicated the resident had capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS a standardized assessment and care-screening tool) dated [DATE] indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated the resident needed extensive assistance from staff for daily activities (bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS indicated that resident was occasional incontinent for bowel and bladder.
A review of Resident 1 ' s Physician Order dated [DATE] indicated an order for Toprol XL (medication used to treat high blood pressure, chest pain and abnormal rhythms of the heart) extended release 24 hour (medication is delivered slowly into the body) 25 milligrams (mg-unit of measure) one tablet by mouth one time a day for hypertension (uncontrolled elevated blood pressure), hold for systolic blood pressure (sbp-pressure in the arteries when the heart beats) less than 110 and heart rate less than 60.
A review of Resident 1 ' s Medication Administration Record (MAR) dated 8/2023, indicated the resident received Toprol XL at 7:30 a.m., on the following dates with sbp:
1. [DATE] – sbp 105/59
2. [DATE]- sbp 106/64
3. [DATE]- sbp 98/78
A review of Resident 1 ' s Care Plan on hypertension dated [DATE] indicated an intervention to give anti-hypertensive medications as ordered.
During a concurrent interview and record review on [DATE] at 11:39 a.m., with the Director of Nursing (DON). Resident 1 ' s Physician Order dated [DATE] and MAR dated 8/2023 were reviewed. The Physician Order indicated Toprol XL 25 mg by mouth daily and hold for sbp less than 110 and heart rate less than 60. The DON stated the resident received the medication on [DATE], [DATE] and [DATE] despite the blood pressure below 110.
During an interview on [DATE] at 11:47 a.m., Registered Nurse 1 (RN 1) stated a check mark in the MAR indicates the medication was given. RN 1 stated nurses should follow physician ' s order to prevent hypotension (low blood pressure).
During an interview on [DATE] at 12:19 p.m., the DON stated Licensed Vocational Nurse 1 (LVN 1) should follow physicians order and should have held the medication to prevent further drop in blood pressure.
A review of facility ' s policy and procedure titled, Administering Medications dated 4/2019 and reviewed on 5/2023, indicated Medications are administered in accordance with the prescribers ' orders, including any required time frame. The following information is checked/verified for each resident prior to administering medications:
b. Vital signs, if necessary.
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 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 manage pain for two of three sampled residents (Resident 1 and Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed manage pain for two of three sampled residents (Resident 1 and Resident 2) by:
1. Failing to notify the physician when Resident 1 had pain level of four (0- no pain, 10 severe pain) on [DATE].
2. Failing to follow physicians order for tramadol hydrochloride (HCL, medication used to treat pain) by mouth as needed for severe pain level of seven to ten when Resident 1 complained of pain level seven on [DATE].
3. Failing to follow physician order for oxycodone HCL (medication used to treat pain) 10 mg by mouth as needed for severe pain level of seven to ten when Resident 2 complained of pain level seven on [DATE], [DATE] and [DATE] and pain level of eight on [DATE] and [DATE].
4. Failing to follow physician order for oxycodone HCL 10mg by mouth as needed for severe pain level of seven to ten when Resident 2 complained of pain level seven on [DATE] at 12:04 a.m.
These deficient practices had the potential to negatively affect the residents' physical comfort and had the potential to increase the pain level and result in an unmanageable pain.
Findings:
a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses including atherosclerotic heart disease (thickening or hardening of the arteries [blood vessels that supply oxygen rich blood from the heart]), muscle weakness and end stage renal disease (ESRD- a medical condition in which a person's kidneys stops functioning on a permanent basis leading to the need for a regular course of long-term dialysis [treatment that helps your body remove extra fluid and waste products from your blood] or a kidney transplant [surgery to place a healthy kidney from a living or deceased donor into a person whose kidneys no longer function] to maintain life).
A review of Resident 1 ' s History and Physical dated [DATE] indicated the resident had capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS a standardized assessment and care-screening tool) dated [DATE] indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated the resident needed extensive assistance from staff for daily activities (bed mobility, transfers, dressing, toilet use and personal hygiene).
A review of Resident 1 ' s Medication Administration Record (MAR) dated 8/2023, indicated the resident had a pain level of four (0-no pain, 10 severe pain) on [DATE] during the 7 a.m. to 3 p.m. shift.
A review of Resident 1 ' s Care Plan on at risk for pain dated [DATE] indicated the following interventions:
1. Anticipate the resident ' s need for pain relief and respond immediately to any complaint of pain.
2. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain.
During an interview on [DATE] at 9:44 a.m., Licensed Vocational Nurse 2 (LVN 2) stated the resident did not have orders for pain medication upon admission on [DATE].
During a concurrent interview and record review on [DATE] at 12:51 p.m., with Registered Nurse 2 (RN 2), Resident 1 ' s MAR dated 8/2023 and Progress Notes dated [DATE] were reviewed. The MAR indicated resident had pain level of four on [DATE]. RN 2 stated there was no documentation that physician was notified of resident ' s pain on [DATE]. RN 2 stated LVN 7 should have called the physician to get an order for pain medication.
During an interview on [DATE] at 3:53 p.m., RN 3 stated on [DATE], LVN 7 did not inform her that resident had a pain level of four and that the resident did not have orders for pain medication. RN 3 stated had LVN 7 informed her she could have assess the resident, call the physician, and get an order. RN 3 stated pain medication is important to relieve the resident ' s feeling of discomfort.
During an interview on [DATE] at 11:19 a.m., the Director of Nursing (DON) stated nurses should call and get an order for pain medicine if resident complains of pain.
b. A review of Resident 1 ' s Physician Order dated [DATE] indicated an order for acetaminophen (medication used to treat pain) extra strength tablet 500 mg, give two tablets by mouth every four hours as needed for moderate pain level of four to six.
A review of Resident 1 ' s Physician Order dated [DATE] indicated an order for tramadol hydrochloride (HCL, medication used to treat pain) tablet 50 mg, give one tablet by mouth every six hours as needed for pain level of seven to ten.
A review of Resident 1 ' s MAR dated 8/2023, indicated the resident had pain level of seven on [DATE] during the 3 p.m. to 11 p.m. shift.
A review of Resident 1 ' s MAR dated 8/2023, indicated acetaminophen 500 mg, two tablets by mouth was given on [DATE] at 8:50 p.m., for a pain level of seven.
A review of Resident 1 ' s MAR dated 8/2023 indicated tramadol HCL was not given on [DATE].
A review of Resident 1 ' s Care plan on at risk for pain dated [DATE], indicated an intervention to provide the resident and family with information about pain and options available for pain management. Discuss and record preferences.
During a concurrent interview and record review on [DATE] at 11:19 a.m., with the Director of Nurses (DON), Resident 1 ' s Physicians order dated [DATE] and [DATE], MAR dated 8/2023 and Progress Note dated [DATE] were reviewed. The DON stated the physician ordered acetaminophen 500 mg, two tablets to be given for pain level of four to six and tramadol HCL 50 mg, one tablet for pain level of seven to ten. The DON stated on [DATE], the resident had complained a pain level of seven and was given acetaminophen instead of tramadol HCL at 8:50 p.m.
c. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses including displaced intertrochanteric fracture (broken bone) of the right femur (right hip), difficulty in walking and muscle weakness.
A review of Resident 2 ' s History and Physical dated [DATE] indicated the resident had capacity to understand and make decisions.
A review of Resident 2 ' s MDS dated [DATE] indicated the resident had moderately impaired cognition. The MDS indicated resident needed extensive assistance from staff for bed mobility, transfer from bed to chair, dressing, toilet use and personal hygiene. The MDS indicated resident received opioid (medication used to treat moderate to severe pain).
A review of Resident 2 ' s Physician Order dated [DATE] indicated the following orders:
1. Oxycodone HCL ten mg tablet, give one tablet by mouth every four hours as needed for severe pain level of seven to ten.
2. Oxycodone HCL five mg tablet, give one tablet by mouth every four hours as needed for moderate pain level of four to six.
A review of Resident 2 ' s MAR dated 8/2023, indicated the resident received oxycodone five mg on the following dates and times:
1. [DATE] at 8:07 a.m.- pain level 8
2. [DATE] at 2 a.m. - pain level 8
3. [DATE] at 4:50 p.m.- pain level 7
4. [DATE] at 11:09 a.m.- pain level 7
5. [DATE] at 8:48 p.m.- pain level 7
A review of Resident 2 ' s Care plan on at risk for pain dated [DATE] indicated an intervention to administer medication as ordered.
During a concurrent interview and record review on [DATE] at 9:45 a.m., with LVN 2, Resident 2 ' s Physician Order dated [DATE] and MAR dated 8/2023 were reviewed. The Physician Order indicated oxycodone ten mg for severe pain level of seven to ten and oxycodone HCL five mg for moderate pain level of four to six. LVN 2 stated Resident 2 received oxycodone 5 mg on [DATE] at 8:07 a.m., [DATE] at 2 a.m. and 4:50 p.m., [DATE] at 11:09 a.m. and [DATE] at 8:48 p.m. LVN 2 stated the resident should have been medicated with 10 mg because of her severe pain level and per physician ' s order.
d. A review of Resident 2 ' s Physician order dated [DATE] indicated the following orders:
1. Oxycodone ten mg, one table by mouth every four hours as needed for severe pain level of seven to ten.
2. Tramadol HCL 50 mg, one tablet by mouth every six hours as needed for mild pain level of one to three.
A review of Resident 2 ' s MAR dated 8/2023, indicated the resident received tramadol HCL 50 mg on [DATE] at 12:04 a.m. for pain level seven.
During a concurrent interview and record review on [DATE] at 9:45 a.m., with LVN 2, Resident 2 ' s Physician Order dated [DATE] and MAR dated 8/2023 were reviewed. The Physician Order indicated oxycodone ten mg for severe pain level of seven to ten and tramadol 50 mg for mild pain level of one to three. LVN 2 stated the resident received tramadol HCL on [DATE] at 12:04 a.m., for pain level of seven. LVN 2 stated resident should have received oxycodone ten mg per physician order. LVN 2 stated nurses should follow physicians order for pain management.
During an interview on [DATE] at 11:19 a.m., the DON stated nurses should follow physician order and administer oxycodone ten mg for severe pain level between seven to ten.
A review of facility ' s policy and procedure titled, Pain Assessment and Management dated 3/2020 and reviewed on 5/2023, indicated Pain Management is a multidisciplinary care process that includes the following:
b. Recognizing the presence of pain.
d. Addressing the underlying causes of pain.
e. Developing and implementing approaches to pain management.
Pain Management interventions shall reflect the sources, type, and severity of pain. Implement the medication regimen as ordered, carefully documenting the results of the interventions. Report the following information to the physician or practitioner:
1. Significant changes in the level of the resident ' s pain.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that medical records were complete, accurately documented, readily accessible and systematically organized for one of four sampled r...
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Based on interview and record review, the facility failed to ensure that medical records were complete, accurately documented, readily accessible and systematically organized for one of four sampled residents (Resident 1). Licensed Vocational Nurse 1 (LVN 1) did not accurately document the location of Resident 1's eye redness and discharge.
This deficient practice had the potential for delayed medical interventions for Resident 1 and potential for error.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 7/27/2023, with diagnoses including type two diabetes mellitus (occurs when the blood sugar is too high), osteoporosis (a condition that causes bones to become weak and lose their strength, making them break more easily than normal bones), and essential hypertension (occurs when a person has abnormally high blood pressure that was not the result of a medical condition).
A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 7/30/2023, indicated the resident's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact. The MDS indicated that Resident 1 required limited assistance (resident highly involved in activity and staff provided guided maneuvering) on bed mobility and personal hygiene. Resident 1 required extensive assistance (resident involved in activity and staff provide weight-bearing support) on toilet use.
A review of Resident 1's Progress Notes, dated 7/30/2023, indicated LVN 1 documented that the resident had drainage and redness in the left eye.
A review of Resident 1's Change in Condition Evaluation (COC), dated 7/30/2023, indicated that the resident had an increased discharge and redness on the left eye. There was no previous documentation indicating that Resident 1 had eye drainage and redness. The primary care doctor and the family were notified.
A review of Resident 1's Care Plans, dated 7/30/2023, indicated that the resident had redness and discharge on the right eye with altered mental status. Resident 1's care plan indicated the resident will be free of discharge and redness on the right eye. The care plan intervention indicated that Resident 1 was monitored for increased drainage on the left eye.
On 8/14/2023 at 12:15 p.m., during a concurrent interview and record review, the Assistant Director of Nursing (ADON) confirmed the discrepancy in the documentation of the location of Resident 1's eye discharge and redness. The ADON stated that documentation should be complete and accurate.
On 8/14/2023 at 12:38 p.m., during a concurrent interview and record review, LVN 1 stated that Resident 1 had a discharge and redness on the left eye. The care plan and the COC were reviewed with LVN 1 and confirmed that the discharge and redness was on the right eye. LVN 1 stated that she made a mistake in documentation of the location of Resident 1's eye discharge and redness.
On 8/14/2023 at 1:15 p.m., during an interview, the Director of Nursing (DON) stated that documentation should be accurate, factual, complete, and timely. The DON further stated that the inaccurate and incomplete documentation had the potential to result in misleading information and wrong medical treatment.
A review of the facility's policy and procedure titled, Charting and Documentation, dated 5/2023, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychological condition shall be documented in the resident's medical record. The policy indicated that the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy also indicated that documentation in the medical record will be objective, complete, and accurate.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for one of four sampled residents (Resident 1) when the air conditioning vents in Resident 1 ' s room were observed closed. This deficient practice resulted in Resident 1 to feel uncomfortable during the day while inside their room and disrupted their sleep at night.
Findings:
A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE], is self-responsible, and had diagnoses including hypertension (high blood pressure) and hyperlipidemia (high cholesterol).
A review of Resident 1 ' s History and Physical (H&P), dated 8/5/2023, indicated Resident 1 has the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS – an assessment and care-screening tool), dated 6/24/2023, indicated Resident 1 was cognitively intact (able to understand and make decisions).
During a concurrent observation and interview with Resident 1, on 7/27/2023, at 11:19 AM, inside Resident 1 ' s room, Resident 1 ' s room felt warm. An air conditioning vent, located on the ceiling in the middle of Resident 1 ' s room, was observed with little airflow coming from the vent. The area around Resident 1 ' s bed was observed and there was no cool airflow observed. Resident 1 stated they do not feel the cool air coming from the vent from the ceiling. Resident 1 stated the temperature inside the room does not feel homelike and would like to have the room cooler. Resident 1 stated the temperature has affected his ability to sleep consistently throughout the night as it would wake them up due to being uncomfortable.
During a concurrent observation and interview with the Maintenance Supervisor (MS), on 7/27/2023, at 12:55 PM, inside Resident 1 ' s room, the temperature in Resident 1 ' s was checked using MS ' s temperature gun. MS was observed checking the temperature on Resident 1 ' s bed and the temperature gun indicated a temperature of 77.2 degrees Fahrenheit. MS was observed checking the temperature on the air conditioning vent, located on the ceiling in the middle of Resident 1 ' s room, and the temperature gun indicated a temperature of 73 degrees Fahrenheit. The MS stated the air conditioning vent was closed and there was no cool air being distributed to Resident 1 ' s room.
During an interview with the MS, on 7/27/2023, at 1:00 PM, the MS stated the temperature coming out from the air conditioning vent should be 10 to 20 degrees cooler than the temperature in the room.
During an interview with the Social Services Director (SSD), on 7/27/2023, at 3:26 PM, the SSD stated comfort is dependent on the resident and should be catered to the resident ' s comfort level because this is where they live.
A review of the facility ' s policy and procedure (P&P) titled, Quality of Life – Homelike Environment, dated 5/2017, indicated residents are provided with a safe, clean, comfortable and homelike environment. The P&P further indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting, including comfortable and safe temperatures.
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
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain the resident's right to privacy and confidentiality by failing to ensure the resident's right to receive mails unopened for one of...
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Based on interview and record review, the facility failed to maintain the resident's right to privacy and confidentiality by failing to ensure the resident's right to receive mails unopened for one of one sampled resident (Resident 1).
This deficient practice violated Resident 1's right to to receive mails unopened.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 6/20/2023, with diagnoses including encephalopathy (a condition that affects the brain, leading to altered brain function and symptoms such as confusion, memory problems, and changes in behavior) and type 2 diabetes mellitus (a chronic condition where the body has difficulty regulating blood sugar levels) with hyperglycemia (refers to high levels of glucose [sugar]) in the blood).
A review of Resident 1's History and Physical dated 4/6/2023, indicated the resident has the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/7/2023, indicated the resident required supervision with bed mobility, transfer, walk in room and corridor, locomotion on and off unit, toilet use, eating, and personal hygiene with setup help only.
During an interview on 7/18/2023 at 8:47 a.m., Resident 1 stated the Administrator (ADM) brought an unlabeled certified mail envelope that was open to the resident.
During an interview on 7/18/2023 at 9:06 a.m., the ADM stated he inadvertently opened Resident 1's mail because it did not have the recipient information. The Adm stated the mail courier removed the certified mail label on the resident's mail.
During an interview on 7/18/2023 at 11:08 a.m., the Business Office Manager (BOM) stated he handed the mail to the ADM, which he later found out belonged to Resident 1.
During an interview on 7/18/2023 at 11:20 a.m., Receptionist 1 (RCP 1) stated she does not go through the mail and does not check any labels including recipient name or addresses. RCP 1 stated once she signs receipt of certified mail delivered by the United Sates Postal Service (USPS, a government agency that delivers mail and packages to homes and businesses across the country), the mail courier takes the label off.
During an interview on 7/19/2023 at 2:17 p.m., the ADM stated the residents have the right to receive their mails unopened and their right for privacy.
A review of the facility's policy and procedure titled, Mail and Electronic Communication, approved on 5/2023 to 5/2024, indicated that residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail and mail will be delivered to the resident unopened.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure prompt attempts were made to resolve the grievances for one of one sampled resident (Resident 1).
These deficient pract...
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Based on observation, interview and record review, the facility failed to ensure prompt attempts were made to resolve the grievances for one of one sampled resident (Resident 1).
These deficient practices had the potential to result in psychosocial harm due to the violation of the resident's right to have their complaint or concern addressed and resolved.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 6/20/2023 with diagnoses including encephalopathy (a condition that affects the brain, leading to altered brain function and symptoms such as confusion, memory problems, and changes in behavior) and type 2 diabetes mellitus (a chronic condition where the body has difficulty regulating blood sugar levels) with hyperglycemia (refers to high levels of glucose [sugar]) in the blood).
A review of Resident 1's History and Physical, dated 4/6/2023, indicated the resident has the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/7/2023, indicated the resident required supervision with bed mobility, transfer, walk in room and corridor, locomotion on and off unit, toilet use, eating, and personal hygiene with setup help only.
During an interview on 7/18/2023 at 8:35 a.m., Resident 1 stated the temperatures in her room is always cold at 2 a.m. Resident 1 stated she has informed the night nurses about her complaint andf the nurses told her they could not adjust the air conditioning thermostat setting because it needed some kind of key and the person responsible for adjusting the thermostat arrives at 7 a.m. Resident 1 stated when it gets cold at night, she puts on layers of sweaters.
During an interview on 7/19/2022 at 5:15 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had ongoing complaints about her room always being cold. LVN 1 stated the nurses would only be able to adjust the thermostat setting during her shift if the nursing supervisor (NS) is working because the NS has the key to access the thermostat. LVN 1 stated if there is no nursing supervisor during her shift, she would wait for the housekeeper or maintenance staff to come in at 7 a.m. or 8 a.m.
During a concurrent observation and interview on 7/19/2023 at 5:22 a.m., LVN 1 stated she does not have the key to adjust the thermostat settings. LVN 1 stated she is unable to read the temperatures in both thermostat located in station 2 because the thermostats are enclosed in a box. LVN 1 stated she does not know who holds the key to open the box.
During an interview on 7/19/2023 at 1:16 p.m., the Social Services Director (SSD) stated the nurses should have informed social services staff about the resident's concerns so that the maintenance staff will be able to address the resident's concerns on temperatures.
During an interview on 7/19/2023 at 2:12 p.m., the Director of Nursing (DON) stated there should have been a documentation regarding Resident 1's complaint and what was done to address the complaint. The DON stated the residents have the right to have their grievances addressed right away.
A review of the facility's policy and procedure titled, Grievances/Complaints, Filing, approved on 5/2023 to 5/2024, indicated that the Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.
Jun 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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to document the treatment provided for one of one sampled resident (Resident 1), by failing to document the treatments provided in the residen...
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Based on interview and record review, the facility failed to document the treatment provided for one of one sampled resident (Resident 1), by failing to document the treatments provided in the resident's treatment administration record (TAR, details administration history by medication/treatments for a selected month) for the month of 6/2023.
This deficient practice had the potential to result in incomplete services provided to Resident 1.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 4/4/2023 with diagnosis including paranoid schizophrenia (a condition of a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) and opioid dependence (this develops as a result of chemical changes in the brain occuring with the chronic use of a broad group of pain-relieving drugs).
A review of Resident 1's History and Physical, dated 4/6/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1's Physician Orders indicated the following orders:
- dated 6/15/2023, monitor left ankle and foot swelling due to resident claimed that she twisted her ankle every shift for 14 days.
- dated 6/20/2023, monitor skin integrity use of the Controlled Ankle Movement boot (CAM, works by both keeping the foot and ankle fixed in place, and removing some of the weight off the foot and ankle while the person continues to walk) to left ankle every shift. Notify MD for skin breakdown, skin discoloration, pain, swelling left foot and ankle every shift.
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/8/2023, indicated the resident with limited assistance with walk in room and corridor, bed moblity, transfer, dressing, toilet use, and personal hygiene.
During a concurrent interview and record review of Resident 1s TAR for month of 6/2023, on 6/30/2023 at 11:29 a.m., Licensed Vocational Nurse 3 (LVN 3) stated the licensed nurses signs the treatment record to show that they have provided the treatment, monitored as ordered, checked to make the resident does not have complications, and that it was done.
During concurrent interview and record review of Resident 1 ' s TAR for month of 6/2023, on 6/30/2023 at 11:41 a.m., the Director of Nursing (DON) stated there were missing initials for left ankle swelling monitoring orders and the use of the CAM boot to left ankle every shift. The DON stated the licensed nurses sign the treatment record that the treatment was administered.
A review of the facility's policy and procedure titled, Charting and Documentation, reviewed and approved on 5/2023 to 5/2024, indicated that all services provided to the resident, progress toward the care plan goals, or any changes inthe resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical records should facilitate communication between the interdisicplinary team (IDT, a group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) regarding the resident's condition and response to care. The procedure indicated medications administered, treatments or services performed is to be docmented in the resident's medical record.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to implement infection control practices for one of one sampled resident (Resident 8), by failing to ensure Certified Nursing As...
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Based on observation, interview, and record review, the facility failed to implement infection control practices for one of one sampled resident (Resident 8), by failing to ensure Certified Nursing Assistant 3 (CNA 3) wore gown before providing peri-care (involves cleaning the private areas of a patient) to Resident 8, who was placed on enhanced barrier precations (EBPs, an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of multi-drug resistant organism [MDRO ,a bacteria that is resistant to many antibiotics (a drug used to treat infections caused by bacteria and other microorganisms)]).
This deficient practice had the potential to spread infection among residents.
Findings:
A review of Resident 1's admission Record indicated the facility readmitted the resident on 6/14/2023 with diagnosis including acute respiratory distress syndrome (a serious lung condition that causes low blood oxygen) and Alzheimer's disease (a brain disease that slowly destroys brain cells).
A review of Resident 1's History and Physical, dated 6/15/2023, indicated the resident does not have the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/6/2023, indicated the resident required extensive assistance with bed mobility, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene, and totally dependent with transfer.
A review of Resident 1's MDRO care plan, dated 6/23/2023, indicated the resident with goals of being free from complications related to infection with interventions including contract isolation (sed for patients with diseases caused by microorganisms [bacteria and viruses] that are spread through direct and indirect contact).
During an observation on 6/29/2023 at 11:03 a.m., observed CNA 3 provided peri-care to Resident 8 and did not wear gown. Observed CNA 3 wearing surgical mask and gloves only. CNA 3 then bagged the soiled linens in a clear plastic bag, changed her gloves, and continued care.
During a concurrent observation and interview on 6/29/2023 at 11:15 a.m., outside Resident 8 ' s room, CNA 3 stated enhanced precautions posted outside of door with notation noted for bed A and Resident 8. CNA 3 stated for Resident 8 she was required to wear gown when she cleans or changes the resident. CNA 3 stated she forgot because she went to see bed A resident then changed Resident 8. CNA 3 stated she should have worn the gown because her supervisor told her because the resident recently came back from the hospital. CNA 3 stated resident had urine and no bowel movement. CNA 3 stated she provided peri-care and mouth care to Resident 8.
During an interview on 6/30/2023 at 10:23 a.m., the Director of Nursing (DON) stated DON stated the enhanced barrier precautions for residents with MDRO, staff have to wear gown before providing peri-care. The DON stated when the staff wear the gown it protects other residents by preventing the spread of infection.
A review of the facility's policy and procedure titled, Enhanced Barrier Precauions, reviewed and approved 5/2023 to 5/2024, indicated that EBPs are utilized to prevent the spread of MDROs to residents. The procedure indicated that gloves and gown are applied prior to performing high contact resident care activity, examples include providing hygiene, changing linens, changing briefs, or assisting with toileting.
Jun 2023
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 5 and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 5 and Resident 3) had the right to be treated with dignity when facility did not promptly answer residents' calls for assistance.
This deficient practice had the potential to result to Resident 5 and Resident 3 feeling helpless and a delay in care.
Findings:
a. A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 6/2/203 with diagnoses that included aftercare following joint replacement surgery (a procedure in which a surgeon removes a damaged joint and replaces it with a new, artificial part), hypertension (uncontrolled elevated blood pressure), and muscle weakness.
A review of Resident 5 ' s Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 6/9/2023, indicated Resident 5 had intact cognition (mental action or process of acquiring knowledge and understanding). Resident 5 needed limited assistance from staff for bed mobility, dressing, personal hygiene, and toilet use. The MDS indicated the resident had occasional pain level of four out of 10 (0- no pain and 10-severe pain).
A review of Resident 5 ' s Grievance log, dated 6/15/2023, indicated resident reported that when she turns the call light, she does not receive a response in 30 minutes. The Grievance Log also indicated resident had notified Social Service that her husband had to get a water for her when he comes visit.
During an interview on 6/17/2023 at 9:21 a.m., Resident 5 stated the nurses at night does not answer the call light and she had to walk out of the room to look for a staff just to ask for pain medicine.
During an interview on 6/17/2023 at 9:24 a.m., Family Member 1 (FM 1) stated that when he comes and visit, he had to walk out of the room and ask the staff for pain medicine, but he gets directed to wait back to the room and he had to wait until someone arrives just to ask for what they need.
During an interview on 6/17/2023 at 10:14 a.m., Certified Nursing Assistant 2 (CNA 2) stated Resident 5 informed her that call light was not answered at night.
During an interview on 6/17/2023 at 11:16 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 5 informed her that call lights were not answered at night. LVN 1 stated other resident had the same concern.
b. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 5/4/2023 with diagnoses that included end stage renal disease (ESRD-a medical condition in which a person's kidneys stop functioning on a permanent basis), fluid overload (excess fluid in the body), and dependent on renal dialysis (a treatment to clean your blood when your kidneys are not able to. It helps your body remove waste and extra fluids in your blood).
A review of Resident 3 ' s History and Physical (H&P) dated 5/5/2023, indicated Resident 3 had the capacity to understand and make decisions.
A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 had intact cognition. The MDS indicated Resident 3 needed extensive assistance from staff for bed mobility, transfers, dressing, personal hygiene, and toilet use.
On 6/18/2023 at 4:42 p.m., observed Certified Nursing Assistant 1 (CNA 1) left Resident 3 ' s room with call light on.
c. A review of Resident 12 ' s admission Record indicated the facility admitted the resident on 12/29/2020 with diagnoses that included chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems), hypertension, and acute kidney failure (a sudden episode of kidney damage that happens within a few hours or a few days).
A review of Resident 12 ' s MDS, dated [DATE], indicated Resident 12 had intact cognition.
On 6/18/2023 at 4:43 p.m., observed Resident 12 standing by his doorway and shouting at CNA 1 to turn off the call light in Resident 3's room but CNA 1 continued to walk away.
During an interview on 6/18/2023 at 4:44 p.m., CNA 1 stated she left the call light on Resident 3 ' s room to look for Registered Nurse 2 (RN 2). CNA 1 stated she should have turned off the call light before leaving the room.
During an interview on 6/18/2023 at 4:47 p.m., Resident 3 stated nurses does not respond to call light. Resident 3 stated she thinks they do not hear it when she calls.
During an interview on 6/18/2023 at 5:55 p.m., RN 2 stated CNA 1 should have turned off the call light before she left the room and look for the staff.
During an interview on 6/20/2023 at 11:34 a.m., the Director of Nursing (DON) stated staff should respond timely and turn off the call light after answering and before leaving the room.
A review of facility ' s policy and procedure titled, Answering the Call Light, dated 10/2010 and reviewed on 5/2023, indicated, Answer the resident ' s call as soon as possible. Turn off the signal light. If assistance is needed when you enter the room, summon the help by using the call signal.
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 F0838
(Tag F0838)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement the staffing plan according to the facility ' s assessment for two of two days (6/10/2023 and 6/11/2023), by failing to ensure di...
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Based on interview and record review, the facility failed to implement the staffing plan according to the facility ' s assessment for two of two days (6/10/2023 and 6/11/2023), by failing to ensure direct care staff (provide support to clients who are unable to perform routine daily activities without assistance) were scheduled based on the required minimum staffing regulations of 3.5 and 2.4 Certified Nursing Assistant (CNA) Direct Care Service Hours Per Patient Day (DHPPD) and patient acuity (refers to severity of the patient ' s illness).
This deficient practice had the potential to delay necessary care and services.
Findings:
A review of the Facility ' s Census indicated the following residents:
- On 6/10/2023, 123 in-house residents.
- On 6/11/2023, 122 in-house residents.
During a concurrent interview and record review of NHPPD on 6/16/2023 at 10:34 a.m., the Director of Nursing (DON) stated the facility does not have a staffing waiver. The DON stated the staffing requirements for actual DHPPD is 3.5 and actual CNA DHPPD is 2.4. The DON confirmed the following:
Saturday, 6/10/2023, Actual DHPPD 3.01 and Actual CNA DHPPD 2.10
Sunday, 6/11/2023, Actual DHPPD 3.08 and Actual CNA DHPPD 2.26
During an interview on 6/16/2023 at 2:27 p.m., the DON stated on 6/10/2023 and 6/11/2023 did not meet the required 3.5 and 2.4 CNA DHPPD staffing requirements. The DON stated the importance of meeting the required staffing requirements is to provide better quality patient care. The DON stated not meeting the required staffing would likely affect the patient care quality.
A review of the facility ' s Facility Assessment (FA) Tool, dated 2/2023, indicated the facility ' s general approach to staffing to ensure the facility have sufficient staff to meet the needs of the residents at any given time. The FA Tool indicated the facility ' s staffing plan for direct care staff is scheduled based on required minimum staffing regulations and patient acuity.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 9, R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 9, Resident 10, and Resident 11) were provided supervision while smoking in the smoking area as indicated in the residents' care plan.
This deficient practice may result in injury to Resident 9, Resident 10, and Resident 11.
Findings:
a. A review of Resident 9 ' s admission Record indicated the facility admitted the resident on 11/9/2021 with diagnoses that included chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems), diabetes mellitus (uncontrolled elevated blood sugar), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily living).
A review Resident 9 ' s History and Physical (H&P), dated 6/29/2022, indicated the resident had the capacity to understand and make decisions.
A review of Resident 9 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/15/2023, indicated Resident 9 had intact cognition (mental action or process of acquiring knowledge and understanding).
A review of Resident 9 ' s Smoking Assessment, dated 6/5/2023, indicated the resident can smoke with periodic supervision.
A review of Resident 9 ' s Care Plan on smoking, dated 11/10/2021, indicated an intervention for supervision.
b. A review of Resident 10 ' s admission Record indicated the facility admitted the resident on 5/26/2022 with diagnoses that included streptococcal infection (throat infection), cellulitis (bacterial skin infection) of left upper limb (arms), and other seizures (uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body).
A review Resident 10 ' s History and Physical, dated 5/29/2022, indicated the resident had the capacity to understand and make decisions.
A review of Resident 10 ' s MDS, dated [DATE], indicated Resident 10 had intact cognition. The MDS indicated the resident needed limited one person assists from staff for bed mobility, transfers, dressing, personal hygiene, and toilet use.
A review of Resident 10 ' s Smoking Assessment, dated 6/2/2023, indicated the resident can smoke with periodic supervision.
A review of Resident 10 ' s Care Plan on smoking, dated 12/28/2022, indicated an intervention for supervision.
c. A review of Resident 11 ' s admission Record indicated the facility admitted the resident on 1/30/2017 with diagnoses that included chronic embolism (a clot or an air bubble obstructing an artery) and thrombosis (blood clot in blood vessels) of unspecified deep veins of left lower extremity (legs), fibromyalgia (a long-lasting disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping) and hypertension (uncontrolled elevated blood pressure).
A review Resident 11 ' s History and Physical, dated 10/23/2022, indicated the resident had the capacity to understand and make decisions.
A review of Resident 11 ' s MDS, dated [DATE], indicated Resident 11 had intact cognition. The MDS indicated the resident needed extensive one person assists from staff for bed mobility, transfers, dressing, personal hygiene, and toilet use.
A review of Resident 11 ' s Smoking Assessment, dated 5/3/2023, indicated the resident can smoke with periodic supervision.
A review of Resident 11 ' s Care Plan on smoking, dated 8/6/2019, indicated an intervention that resident is only allowed to smoke with supervision.
During an observation on 6/18/2023 at 5:10 p.m., in the smoking area, observed three of four residents seated on their wheelchairs were smoking unsupervised.
During a concurrent observation and interview on 6/18/2023, at 5:15 p.m., with Certified Nursing Assistant 6 (CNA 6), in the smoking area, three residents were observed smoking with no supervision. CNA 6 identified two (Resident 10 and Resident 11) of the three residents and confirmed no staff was present while they were out smoking. CNA 6 stated Activity Staff 1 (AS 1) was probably taking a break.
During an interview on 6/18/2023 at 5:16 p.m., AS 1 stated he supervises the smokers on weekends from 8:30 a.m., to 5 p.m. only. AS 1 stated he was not sure who supervises them after he leaves.
During a concurrent observation and interview on 6/18/2023 at 5:18 p.m., with Registered Nurse 2 (RN 2), in the smoking area entrance. RN 2 identified the third smoker as Resident 9. RN 2 stated nurses supervises the smokers after 5 p.m., on weekends. RN 2 stated smokers needed to be supervised for safety purposes.
During an interview on 6/20/2023 at 8:46 a.m., the Director of Nursing (DON) stated smokers needed supervision while smoking in the smoking area to ensure their safety.
A review of facility ' s policy and procedure titled, Smoking Policy-Residents, dated 7/2017 and reviewed on 5/2023, indicated, Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted in the care plan, and all personnel caring for the resident shall be alerted to these issues. Any resident with restricted smoking privilege requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking.
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 F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure that residents who require hemodialysis (process of purifying the blood of a person whose kidneys are not working normally) receive ...
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Based on interview and record review, the facility failed to ensure that residents who require hemodialysis (process of purifying the blood of a person whose kidneys are not working normally) receive treatment in accordance with standards of practice for one of four sampled residents (Resident 3) by:
1. Failing to ensure Resident 3 had transportation to the Dialysis Center on 6/10/23 and 6/12/23.
2. Failling to implement the physician ' s order for monitoring of abdominal girth.
3. Failing to initiate a care plan for missed hemodialysis due to transportation issue on 6/10/2023.
4. Failing to notify physician of missed hemodialysis on 6/12/2023.
These deficient practices had the potential to place Resident 3 at risk for fluid overload.
Findings:
1. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 5/4/2023 and readmitted from General Acute Care Hospital (GACH 1) on 6/16/2023 with diagnoses including End-Stage Renal Disease ( ESRD -long-lasting disease of the kidneys leading to renal failure), fluid overload (too much fluid in the body), and type 2 diabetes mellitus (body does not make enough insulin or cannot use it as well as it should).
A review of Resident 3 ' s History and Physical, dated 5/5/2023, indicated that resident had the capacity to understand and make decisions.
A review of Resident 3 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/8/2023, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 3 required extensive one-person assistance from staff for bed mobility, dressing, toileting, and personal hygiene. The MDS indicated Resident 3 needed two persons assist for transferring and resident uses a wheelchair.
A review of Resident 3 ' s Physician Order, dated 5/8/2023, indicated hemodialysis (HD) scheduled at Dialysis Center 1 (DC 1) on Tuesday, Thursday, and Saturday, with chair time (start time) at 3 a.m. Resident 3's pickup time is at 2: 30 a.m.
A review of Resident 3 ' s Physician Order, dated 6/10/2023, indicated Saturday ' s (6/10/2023) dialysis did not go through due to transportation issues. Extra hemodialysis was rescheduled for Monday (6/12/2023) at 10:30a.m.
A review of Resident 3 ' s Dialysis Communication Records indicated no records found for 6/10/23 and 6/12/2023.
A review of Resident 3 ' s Attending Progress Note (APN), dated 6/16/2023, indicated the resident missed HD on 6/10/2023 due to transportation arriving late and was rescheduled for 6/12/2023. The APN indicated transportation was canceled again and Resident 3 did not have the HD on 6/12/2023.
During an interview on 6/20/2023 at 3 p.m. in Resident 3 ' s room, resident stated her dialysis days are Tuesday, Thursday, and Saturday. Resident 3 stated she missed one HD because transportation did not pick her up. Resident 3 stated her right foot feels worse and swollen.
During an interview on 6/21/2023 at 11:48 a.m., the Social Services Director (SSD) stated she is arranging transportation for dialysis by calling resident ' s insurance. SSD stated if any problem with transportation after office hours nurse can call insurance for estimated time of arrival or reschedule pick up time. SSD stated the facility do not have a private transportation to take residents to their dialysis center and they do not have a transportation log in the facility for dialysis.
During an interview on 6/21/2023 at 12:58 p.m., Licensed Nurse 7 (LVN 7), stated in case of missed dialysis, LVN should notify physician for further order and resident had to be monitored for signs and symptom of fluid overload.
During a concurrent interview and record review on 6/21/2023 at 1:33p.m. with Registered Nurse 3(RN 3), Resident 3 ' s Progress Note (PN) dated 6/10/2023 was reviewed. PN indicated Resident 3 missed HD on 6/10/2023. RN 3 verified Resident 3 missed dialysis on 6/10/2023 due to transportation issues. RN 3 stated the nurse should notify a physician for further orders to prevent fluid overload.
During an interview on 6/21/2023 at 3:40 p.m., the Director of Nursing (DON) stated Resident 3 missed dialysis on 6/10/2023 and 6/12/2023 due to transportation issue. The DON stated missed dialysis may cause fluid overload. The DON stated they do not have a policy for missed HD but if two missed HD they transfer the resident to GACH.
2. A review of Resident 3 ' s Order Summary Report, dated 6/5/2023, indicated to monitor for abdominal girth weekly every Monday.
A review of Resident 3 ' s Treatment Administration Record (TAR), dated 6/2023, indicated on 6/5/2023, 6/12/2023, 6/19/2023 were left blank.
During a concurrent interview and record review on 6/21/2023 at 1:33 p.m., with RN 3, Resident 3 ' s TAR dated 6/2023 was reviewed. The TAR was left blank on 6/5/2023, 6/12/2023 and 6/19/2023. RN 3 confirmed 6/5/2023 and 6/12/2023 left blank, but on 6/19/2023 nurse documented 46 inches girth.
During an interview on 6/21/2023 at 3:40 p.m., the DON stated abdominal girth monitoring was not done and documented on 6/5/2023 and 6/12/2023. The DON stated nurses should follow physician order to monitor for fluid overload.
A review of facility ' s policy and procedure titled, Charting and Documentation, dated 7/2017 and reviewed on 5/2023, indicated, The following information is to be documented in the resident medical record:
a. objective observations
c. treatments or services performed.
3. A review of Resident 3 ' s care plans on hemodialysis indicated no care plan was initiated or revised for missed hemodialysis on 6/10/2023 and 6/12/2023.
During a concurrent interview and record review on 6/21/2023 at 2:34 p.m., with RN 3, Resident 3 ' s Care Plans was reviewed. RN 3 stated no care plan was initiated on 6/10/2023 or 6/12/2023 for missed hemodialysis.
During an interview on 6/21/2023 at 4:49 p.m., the DON stated there was no care plan initiated on 6/10/2023 or 6/12/2023 for missed hemodialysis. The DON stated care plans are important to implement individualized intervention.
A review of facility ' s policy and procedure titled, Care of a Resident with End- Stage Renal Disease (ESRD), dated 10/2010 and reviewed on 5/2023, indicated, Agreements between this facility and the contracted ESRD facility include all aspects of how the resident ' s care will be managed, including: a. How the care plan will be developed and implemented.
A review of facility ' s policy and procedure titled, Charting and Documentation, dated 7/2017 and reviewed on 5/2023, indicated, The following information is to be documented in the resident medical record:
e. events, incidents or accidents involving the resident and
f. Progress toward or changes in the care plan goals and objective.
4. A review of Resident 3 ' s Progress Note (PN) dated 6/12/2023 indicated physician was not notified that HD was not done due to transportation issue.
During a concurrent interview and record review on 6/21/2023 at 2:34 p.m., with RN 3, Resident 3 ' s PN dated 6/12/2023 was reviewed. RN 3 stated on 6/12/2023 there was no documentation that physician was notified of missed hemodialysis.
During an interview on 06/21/2023 at 3:39 p.m., the DON stated LVN 7 did not document that she called the physician on 6/12/2023 of missed hemodialysis. The DON stated nurses should notify the physician to get new orders or if needed to transfer to GACH due to two missed hemodialysis on 6/10/2023 and 6/12/2023. The DON stated the missed two consecutive HDs may result to fluid overload.
A review of facility ' s policy and procedure titled, Change in a Resident ' s Condition or Status, dated 5/2017 and reviewed on 5/2023, indicated, The nurse will notify the resident ' s attending physician or physician on call when there has been a (an): e. need to alter the resident ' s medical treatment significantly. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the residents medical or mental condition or status.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that staff followed physician ' s order for two of four samp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that staff followed physician ' s order for two of four sampled residents (Resident 3 and Resident 5) by:
1. Failing to ensure that Resident 3 was given metoprolol tartrate (medication used to treat high blood pressure) despite physician ' s order to hold the medication if systolic blood pressure (sbp-pressure in the arteries when the heart beats) was below 110 millimeters of mercury (mmHg-unit of measurement) as indicated in the resident ' s Medication Administration Record (MAR- record of medications received by the resident).
2. Failing to ensure that Resident 5 ' s Narcotic and Hypnotic Record (NHR) for hydrocodone-acetaminophen (medication used to treat pain) matches the resident's June 2023 MAR.
This deficient practice placed Resident 3 at risk of developing low blood pressure levels and placed Resident 5 at risk for pain.
Findings:
a. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 5/4/2023 with diagnoses that included end stage renal disease (ESRD-a medical condition in which a person's kidneys stop functioning on a permanent basis), fluid overload (excess fluid in the body), dependent on renal dialysis (a treatment that helps your body remove waste and extra fluids in your blood when your kidneys are not able to) and hypertension (uncontrolled elevated blood pressure).
A review of Resident 3 ' s History and Physical (H&P), dated 5/5/2023, indicated Resident 3 had the capacity to understand and make decisions.
A review of Resident 3 ' s Minimum Data Set (MDS-a standardized assessment and care-screening tool), dated 5/8/2023, indicated Resident 3 had intact cognition. The MDS indicated Resident 3 needed extensive assistance from staff for bed mobility, transfers, dressing, personal hygiene, and toilet use.
A review of Resident 3 ' s Physician Order, dated 5/17/2023, indicated an order for metoprolol tartrate (medication used to lower blood pressure) tablet 25 milligrams (mg- unit of measurement), give half a tablet by mouth two times a day to treat high blood pressure, and if systolic blood pressure (sbp-pressure in the arteries when the heart beats) is less than 110 and heart rate is less than 60 to hold the medication.
A review of Resident 3 ' s Medication Administration Record (MAR- record of medication received by the resident) dated 5/2023 and 6/2023, indicated metoprolol tartrate was given on the following dates with sbp readings:
5/17/2023 -at 9 a.m.- bp 109/74
5/22/2023- at 9 a.m.- bp 109/60
5/24/2023- at 9 a.m.- bp 107/70
5/25/2023- at 9 a.m.- bp 109/69
5/26/2023- at 9 a.m.- bp 108/60
5/29/2023- at 9 a.m.- bp 109/65
5/30/2023- at 9 a.m.- bp 108/65
5/31/2023- at 9 a.m.- bp 108/72
6/1/2023- at 9 a.m.- bp 109/68
6/2/2023- at 9 a.m.- bp 109/67
6/5/2023- at 9 a.m.- bp 109/68
6/9/2023- at 5 p.m., bp 104/76
During a concurrent interview and record review on 6/21/2023 at 11:21 a.m., with Licensed Vocational Nurse 7 (LVN 7), Resident 3 ' s MAR dated 5/2023 and 6/2023 were reviewed. The MAR indicated LVN 7 gave the metoprolol tartrate 11 times at 9 a.m. when sbp was less than 110 mmHg. LVN 7 stated a check mark in MAR indicated medication was given. LVN 7 stated she held the medication but do not know how to document and how to hold the medication in MAR. LVN 7 stated she was not informed on how to do it. LVN 7 stated the importance of accurate medication documentation is to prevent medication error.
During an interview on 6/21/2023 at 11:22 a.m., the Director of Staff Development (DSD) stated a check mark in MAR indicated medication was given. DSD stated LVN 7 should have held the medication per physician order.
During an interview on 6/21/2023 at 11:29 a.m., the Director of Nursing (DON) stated staff should hold the medication because it is a physician's order to prevent hypotension (low blood pressure).
During an interview on 6/21/2023 at 11:59 a.m., LVN 8 stated he did not give the medication and just forgot to document correctly. LVN 8 stated he should be careful in documenting and following the physician order to prevent medication error.
b. A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 6/2/203 with diagnoses that included aftercare following joint replacement surgery (a procedure in which a surgeon removes a damaged joint and replaces it with a new, artificial part), hypertension and gout (kind of arthritis [swelling and tenderness of joint] causing pain.
A review of Resident 5 ' s H&P, dated 5/30/2023, indicated that resident was admitted for pain management.
A review of Resident 5 ' s MDS, dated [DATE], indicated Resident 5 had intact cognition. Resident 5 needed limited assistance from staff for bed mobility, dressing, personal hygiene, and toilet use. The MDS indicated the resident had occasional pain level of four out of 10 (0- no pain and 10-severe pain).
A review of Resident 5 ' s Physician Order, dated 6/5/2023, indicated an order for hydrocodone-acetaminophen (Norco-medication used to treat pain) 10-325 mg, give one tablet by mouth every eight hours as needed for 7-10 pain.
A review of Resident 5 ' s MAR, dated 6/2023, indicated on 6/13/2023 and 6/14/2023 between 3 p.m. to 11 p.m. shift, LVN 2 documented resident ' s pain level at 8 out of 10.
A review of Resident 5 ' s Narcotic and Hypnotic Record (NHR) for hydrocodone-acetaminophen dated 6/2023 and compared to the residents MAR dated 6/2023. The NHR indicated LVN 2 dispense the hydrocodone-acetaminophen on 6/13/2023 at 8:50 p.m., and on 6/14/2023 at 10:30 p.m. The MAR did not indicate that resident received these medications on both days.
A review of Resident 5 ' s Care Plan on pain dated 6/2/2023, indicated an intervention to administer pain medication as per orders.
During an interview on 6/17/2023 at 9:21 a.m., Resident 5 stated her pain medicine was never given when she needed it.
During a concurrent interview and record review on 6/20/2023 at 9:45 a.m., with Registered Nurse 3 (RN 3), Resident 5 ' s NHR and MAR dated 6/2023 were reviewed. The NHR indicated hydrocodone-acetaminophen was signed by LVN 2 on 6/13/2023 at 8:50 p.m., and on 6/14/2023 at 10:30 p.m. The MAR did not indicate that medications were given to Resident 5. RN 3 stated LVN 2 signed the NHR but did not sign the MAR. RN 3 stated both records, the NHR and MAR should match to prevent medication error.
During an interview on 6/20/2023 at 10:50 a.m., the DSD stated if medication was not documented it was not given.
During an interview on 6/20/2023 at 11:34 a.m., the DON stated if LVN 2 documented in the NHR, she should also document in the MAR to prove that Resident 5 was medicated for pain. The DON stated if it is not documented in resident records then it was not given.
During an interview on 6/20/2023 at 4:34 p.m., LVN 2 stated she gave the hydrocodone-acetaminophen on 6/13/2023 and 6/14/2023 but forgot to document in the MAR. LVN 2 stated if it was not documented then medication was not given.
A review of facility ' s policy and procedure titled, Administering Medications, dated 4/2019 and reviewed on 5/2023, indicated Medications are administered in accordance with prescribed orders, including any required time frame. The following information is checked/verified for each resident prior to administering medications:
a. Allergies to medications, and
b. Vitals Signs (blood pressure, heart rate, respiratory rate, and temperature), if necessary
The individual administering the medication, initials the resident ' s MAR on the appropriate line after giving each medication and before administering the next ones.
A review of facility ' s policy and procedure titled, Charting and Documentation dated 7/2017 and reviewed on 5/2023, indicated The following information is to be documented in the resident medical record: c. Medications administered .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to maintain the nursing sign-in sheet (a document where employees signs with their signature verifying their presence in the facility, provide...
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Based on interview and record review, the facility failed to maintain the nursing sign-in sheet (a document where employees signs with their signature verifying their presence in the facility, provided nursing services, and worked the hours stated) from 6/10/2023 to 6/18/2023, by failing to ensure on-duty staff signed the nursing sign-sheet before the start of their shift.
This deficient practice had the potential to result in inaccurate nursing hours computation and incomplete staffing documentation.
Findings:
During a concurrent interview and record review of Nursing Sign-In Sheets and Timecards (a card used with a time clock to record an employee's starting and quitting times each day or on each job), dated 6/10/2023 and 6/11/2023, on 6/16/2023 at 12:43 p.m., the Payroll Staff (PR) stated the following:
- On 6/10/2023, 7 a.m. to 3 p.m., Licensed Vocational Nurse 2 (LVN 2) clocked in but did not sign the sign-in sheet.
- On 6/11/2023, 7 a.m. to 3 p.m. shift, LVN 1 clocked in but did not sign the sign-in sheet.
- On 6/11/2023, 3 p.m. to 11 p.m. shift, LVN 3 clocked in but did not sign the sign-in sheet.
- On 6/11/2023, 11 p.m. to 7 a.m. shift, LVN 14 and LVN 15 clocked in but did not sign the sign-in sheet.
During an interview on 6/16/2023 at 2:34 p.m., the Director of Nursing (DON) stated all nursing staff should sign the nursing sign-in sheet with their signature before starting their shift to ensure proper documentation and recording for tracking purposes. The DON stated they do not have policy regarding Nursing Sign-In Sheets documentation, but the on-duty nursing staff should sign.
During a concurrent interview and record review on 6/17/2023 at 11:07 a.m., with Registered Nurse 1 (RN 1), nursing sign in sheets dated 6/16/2023 to 6/17/2023 were reviewed. The nursing sign in sheet indicated RN 2, LVN 10, Certified Nursing Assistant 2 (CNA 2), CNA 12, CNA 13 and CNA 14 names were not signed. RN 1 stated staff should sign in before the start of their shift.
During an interview on 6/17/2023 at 11:34 p.m., CNA 2 stated he came in late and the nursing sign in sheet was not in the front desk where it should be and when he came in that morning and RN 1 informed him of his assigned nurse ' s station, so he went straight and had forgotten to sign in.
During a concurrent interview and record review on 6/18/2023 at 3:30 p.m., with RN 2, the nursing sign in sheet dated 6/17/2023 to 6/18/2023 was reviewed. The nursing sign in sheet indicated LVN 3, CNA 4, CNA 5, CNA 10, CNA 16, CNA 17 name was not signed. RN 2 confirmed staff did not sign in and stated all staff are supposed to sign beginning of the shift.
During an interview on 6/18/2023 at 4:11 p.m., CNA 4 stated it is her second day today and was not informed to sign the nursing sign in sheet.
During an interview on 6/18/2023 at 4:12 p.m., CNA 10 stated she signed in the nurse ' s station assignment sheet.
During an interview on 6/18/2023 at 4:18 p.m. CNA 5 stated when he came in, the nursing sign in sheet was not with the receptionist.
During an interview on 6/18/2023 at 4:58 p.m., LVN 4 stated the assignment sheet is signed to acknowledge that we are aware of our assigned residents and to acknowledge our break time. LVN 4 stated the nursing sign- in sheet in the front is another form they must sign. LVN 4 stated she worked on 6/17/2023 from 11 p.m., to 6/18/2023 of 7 a.m. and confirmed she worked with CNA 10, CNA 13, and CNA 15 that night.
During a concurrent interview and record review on 6/20/2023 at 3:20 p.m., with the Director of Staff Development (DSD). The nursing sign in sheet dated 6/13/2023 to 6/14/2023 was reviewed. The nursing sign in sheet indicated the following staff signature were left blank by RN 4, LVN 11, LVN 12 and CNA 18. The DSD stated if staff did not sign in, it may affect the nursing hours computation.
During an interview on 6/21/2023 at 3:39 p.m., DON stated all staff must sign at the start of their shift for accurate staffing. DON stated they do not have a policy related to Nursing Sign-In Sheet.
May 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility dietary supervisor failed to develop a comprehensive care plan on food prefe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility dietary supervisor failed to develop a comprehensive care plan on food preferences for one of three sampled residents (Resident 3).
This deficient practice had the potential for delayed provision of necessary care and services.
Findings:
A review of Resident 3 ' s admission record dated 5/9/2023, indicated that the resident was admitted on [DATE] following a joint replacement surgery, with diagnoses including hypertension (increased blood pressure), hyperlipidemia [high cholesterol (fats in the blood)], and cardiac arrythmia (irregular heartbeat).
A review of Resident 3 ' s Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 4/24/2023, indicated that the resident was cognitively intact. The MDS indicated that Resident 3 needed extensive assistance in bed mobility, transfer, walking in room and corridor, locomotion (movement between locations) on and off unit, dressing, toilet use, and personal hygiene, and requiring limited assistance with eating.
On 5/10/2023 at 12:06 p.m., during an interview, the Dietary Supervisor (DS) stated that Resident 3 was picky with food. The DS stated that the resident had a list of food preferences. The DS stated that she visited the resident every single day to check if the resident was eating. The DS stated that there was no care plan food preferences created for Resident 3 as it was overlooked. The DS stated that care plans were created for residents because it individualizes them and each resident has unique needs that needed to be addressed individually. The DS stated that care plans are used to review the effectiveness of the care provided.
On 5/10/2023 at 12:56 p.m. during an interview with the Director of Nursing, the DON stated creating a care plan ensures that the resident ' s needs are addressed in terms of nutrition.
A review of the facility ' s policy on Care Plans, Comprehensive Person-Centered revised on 12/2016 and reviewed on 4/2022, indicated that it is a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs a developed and implemented for each resident; the care plan interventions are derived from a thorough analysis of the information gathered a part of the comprehensive assessment.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident was provided adequate supervision to prevent an elopement for one (Resident 4) of three sampled residents.
This deficient...
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Based on interview and record review, the facility failed to ensure a resident was provided adequate supervision to prevent an elopement for one (Resident 4) of three sampled residents.
This deficient practice potentially placed Resident 4 at risk for injury.
Findings:
A review of Resident 4 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 1/30/2023 with a diagnoses including hemiplegia (severe to a complete loss of strength) and hemiparesis (weakness or the inability to move one side of the body) following cerebral infarction (lack of adequate blood supply to the brain) affecting the right side, seizure (muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking), repeated falls and unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
A review of Resident 4 ' s History and Physical (H&P) dated 3/9/2023, indicated, resident can make needs known but cannotmake medical decisions.
A review of Resident 4 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/6/2023, indicated Resident 4 ' s cognitive (mental action or process of acquiring knowledge and understanding) status was severely impaired. The MDS indicated Resident 4 needed extensive one person assists for bed mobility, transfers, dressing, toilet use and personal hygiene.
A review of Resident 4 ' s Care Plan dated 3/26/2023 on fall incident related to unsupervised outside activity indicated an intervention to monitor resident for elopement (leaving supervised areas without notice) risk.
A review of Resident 4 ' s Care Plan dated 3/31/2023 on elopement risk or wanderer (aimless roaming around) related to attempts to leave facility unattended indicated an intervention to monitor resident for any attempt to wander or go outside unattended and unknown to staff.
A review of Resident 4 ' s Elopement Risk Evaluation (ERE) dated 3/31/2023 indicated the resident is at risk for elopement and wandering.
A review of Resident 4 ' s Medication Administration Record (MAR-medication received by the resident) dated 5/2023, indicated on 5/6/2023, Resident 4 attempted to wander or go outside unattended 18 times and on 5/7/2023, resident attempted to wander or go outside unattended five times.
A review of Resident 4 ' s Change of Condition (COC) dated 5/9/2023, indicated resident was wandering on 5/8/2023 and was found within the facility vicinity.
A review of Resident 4 ' s Progress Notes dated 5/9/2023, indicated resident on monitoring due to episode of wandering on 5/8/2023 at 3 p.m. to 11 p.m. shift.
During an interview on 5/12/2023 at 12:01 p.m., Registered Nurse 1 (RN 1) stated on 5/8/2023 between 9 p.m. to 10 p.m., she was in the Nurse ' s Station 5 when Transporter 1 (T 1) came and informed her that a resident was in front of the facility building. RN 1 stated she saw Resident 4 ' s wheelchair alarm going off by the stairs leading to the sidewalk and the resident was standing ten steps away to the left of the stairs, with an unidentified man holding the resident. RN 1 stated she took the resident back to the facility and assessed with no injury. RN 1 stated they should have supervised the resident when the resident went outside of the facility.
During an interview on 5/12/2023 at 12:18 p.m., Certified Nursing Assistant 3 (CNA 3) stated Resident 4 wanders inside the facility using a wheelchair. CNA 3 stated Receptionist 1 (RCP 1) should have called somebody to stay in the front lobby if she had to leave the front desk.
During an interview on 5/16/2023 at 10:06 a.m., CNA 2 stated she was assigned to take care of Resident 4. CNA 2 stated she saw the resident on 5/8/2023 at 8:30 p.m., seated in the wheelchair in front of the nurse ' s station close to his room. CNA 2 stated she informed Licensed Vocational Nurse 4 (LVN 4) to check on Resident 4 while she was checking her other residents. CNA 2 stated she was in another resident ' s room when she heard a staff calling her name and informing her the resident was outside of the facility. CNA 2 stated Resident 4 needed one to one supervision because he always gets up unassisted.
During an interview on 5/16/2023 at 10:19 a.m., LVN 4 stated she saw Resident 4 seated on a wheelchair on 5/8/2023 at 8:30 p.m., at Nurses Station 2. LVN 4 stated they monitor the resident because he stands up unassisted and had history of fall, has an unsteady gait and requires assistance with activities of daily living (ADL).
During an interview on 5/16/2023 at 11:31 a.m., RCP 1 that stated on 5/8/2023 she left the front desk at 9:35 p.m., to go to the restroom for approximately five to six minutes. RCP 1 stated when she came back, she went to Nurses Station 5 and saw T 1 reporting to RN 1 that there was a resident in the sidewalk. RCP 1 stated she saw Resident 4 outside walking in the sidewalk with an unidentified man holding the resident. RCP 1 stated on 5/8/2023, Resident 4 had attempted to go out of the facility from the front entrance two to three times from 3 p.m., to 9 p.m. had informed LVN 4 of his attempts. RCP 1 stated the front sliding door had no alarm and stated if she had called somebody to stay in the front desk before she left, Resident 4 would have not wandered outside the facility. RCP 1 stated she was not provided an Inservice (education) for wandering and elopement and she was not given an instruction on who to call if she needed to go on short breaks.
During an interview on 5/16/2023 at 12:58 p.m., Director of Nursing (DON) stated the incident was avoidable.
A review of facility ' s policy and procedure titled, Wandering and Elopements dated 3/2019 and reviewed on 4/2022, indicated, The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the lease restrictive environment for residents.
A review of facility ' s policy and procedure titled, Safety and Supervision of Residents dated 7/2017 and reviewed on 4/2022, indicated, Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. Implementing interventions to reduce accident risks and hazards shall include the following:
a. Communicating specific interventions to all relevant staff,
b. assigning responsibility for carrying out interventions
c. providing training as necessary.
Apr 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents were provided with a safe, clean...
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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 residents were provided with a safe, clean, comfortable, and homelike environment for two of three sampled residents (Resident 2 and 3), by failing to maintain that the resident's window had a window screen.
This deficient practice had the potential to result in an unsafe and unclean environment with the spread of pests (insects, bugs, and mosquitoes) by entering the building.
Findings:
a. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/3/2023 with diagnosis including fracture (break-in bone) of right lower leg and muscle wasting and atrophy (wasting or thinning of muscle mass).
A review of Resident 2 ' s History and Physical (H&P), dated 3/3/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/6/2023, indicated the resident required extensive assistance from nursing staff with bed mobility, dressing, toilet use, and personal hygiene and setup help only with eating.
b. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 2/15/2023 with diagnosis including fracture of right femur (thigh bone) and history of falling.
A review of Resident 3 ' s H&P, dated 2/16/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 3 ' s MDS, dated [DATE], indicated the resident required extensive assistance from nursing staff with bed mobility, dressing, toilet use, and personal hygiene and setup help only with eating.
During an observation on 4/27/2023 at 10:38 a.m., observed Resident 2 and 3 lying in bed, with glass window open and with no window screen noted.
During a concurrent observation and interview inside the room of Residents 2 and 3 on 4/27/2023 at 12:14 p.m., the MDS Nurse (MDSN) stated the glass window was left fully opened. Observed MDSN tried to close the window. The MDSN stated Resident 3 motioned to open the window. The MDSN stated she will leave the window open for now and inform maintenance. The MDSN stated the window does not have a screen and only the glass window. The MDSN stated leaving the window open without the screen would allow insects to come in the residents ' rooms and into the building.
During a concurrent observation and interview inside Resident 2 and 3 ' s room on 4/27/2023 at 12:18 p.m., Certified Nursing Assistant 1 (CNA 1) stated she left the window open per Resident 3 ' s request. CNA 1 stated it was already open when she got in this morning and the resident wants it open. CNA 1 stated when she takes care of Resident 3 the window remained open, and she does not close it. Observed CNA 1 attempted to close the window but does not fully close. CNA 1 stated the window does not fully close, there is a gap. CNA 1 stated she will inform the maintenance.
During an interview on 4/27/2023 at 1:21 p.m., the Director of Nursing (DON) stated when the resident ' s windows does not have the window screen then dusts and insects could come in the building. The DON stated there should be a window screen.
A review of the facility ' s policy and procedure titled, Maintenance Service, reviewed 4/2023, indicated that the maintenance service shall be provided to all areas of the building, grounds, and equipment. The procedure indicated that maintenance personnel functions included maintaining the building in good repair and free from hazards.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 2 and 3) maintained...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 2 and 3) maintained acceptable parameters of nutrition, by:
1. Failing to develop care plans addressing Resident 2 and 3 ' s unplanned weight loss.
2. Failing to follow through the registered dietitian ' s recommendations for Resident 2.
These deficient practices had the potential to result in further unplanned weight loss of Residents 2 and 3.
Findings:
a. A review of Resident 2 ' s admission Records indicated the facility admitted the resident on 3/3/2023 with diagnoses including fracture (break-in bone) of right lower leg and muscle wasting and atrophy (wasting or thinning of muscle mass).
A review of Resident 2 ' s History and Physical (H&P), dated 3/3/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/6/2023, indicated the resident required extensive assistance from nursing staff with bed mobility, dressing, toilet use, and personal hygiene and setup help only with eating.
A review of Resident 2 ' s Weights indicated the following:
- 3/3/2023, 129 pounds (lbs, a unit of measure)
- 4/5/2023, 122 lbs
A review of Resident 2 ' s Nutrition Assessment Form, dated 4/6/2023, indicated the resident with recommendations of snacks twice a day and weekly weights x 2 weeks.
A review of Resident 2 ' s Situation, Background, Assessment, Requests (SBAR, system for identifying, evaluating, and reporting deterioration in resident ' s condition) Communication Forms, dated 4/7/2023, indicated the resident with seven pounds weight loss in one month.
During a concurrent interview and record review of Resident 2 ' s clinical record on 4/27/2023 at 11:35 a.m., the MDS Nurse (MDSN) confirmed there were only two weights recorded on 3/6/2023 and 4/5/2023. The MDSN stated the seven lbs weight loss in one month was greater than 5% and was a significant weight change. The MDSN confirmed there were no physician orders for snacks twice a day and weekly weights x 2 after 4/5/2023. The MDSN confirmed there was no care plan developed for Resident 2 ' s weight loss identified on 4/7/2023. The MDSN there should have been a care plan developed and indicating the interventions such as to monitor weight, monitor intake, and any recommendations from the registered dietitian (RD) should be care planned. The MDSN stated when care plans are not developed and the resident ' s physician is not informed of any recommendations from the RD, these would place the resident at risk for nutritional problems such as further weight loss or malnutrition.
b. A review of Resident 3 ' s admission Records indicated the facility admitted the resident on 2/15/2023 with diagnoses including fracture of right femur (thigh bone) and history of falling.
A review of Resident 3 ' s H&P, dated 2/16/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 3 ' s MDS, dated [DATE], indicated the resident required extensive assistance from nursing staff with bed mobility, dressing, toilet use, and personal hygiene and setup help only with eating.
A review of Resident 3 ' s Weights, indicated the following:
- 2/16/2023, 176 lbs
- 3/2/2023, 170 lbs
- 4/5/2023, 166 lbs
During a concurrent interview and record review of Resident 3 ' s clinical record on 4/27/2023 at 11:55 a.m., the MDSN confirmed the resident had 10 lbs weight loss in 10 weeks. MDS stated it is not a significant weight loss but there should be a care plan developed for risk for nutritional problems and prevent further weight loss. MDS stated interventions would include to notify MD for any changes, provide diet as ordered, monitor meal intake, and RD consult as needed. MDS stated Resident 3 did not have a care plan developed addressing the resident ' s weight loss.
During an interview on 4/27/2023 at 1:07 p.m., the Director of Nursing (DON) stated any recommendations relayed to the licensed nurses, could be registered nurses or licensed vocational nurses, to call the doctor and carry out the order. The DON stated the care plan is updated by dietary supervisor or licensed nurses. The DON stated the purpose of an updated care plan is to give appropriate care for that resident. The DON stated the licensed nurses should develop the care plans as soon as possible for change in condition, within that timeframe, and have the interventions in place.
A review of the facility ' s policy and procedure titled, Weight Assessment and Intervention, reviewed on 4/2023, indicated that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for their residents. The procedure indicated 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. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian . individualized care plans shall address the identified causes of weight loss; goals and benchmarks for improvement; timeframes and parameters for monitoring and reassessment.
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 F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to prevent infestation of roaches in one of two sample...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to prevent infestation of roaches in one of two sampled residents ' (Resident 8) room. A dead cockroach was found on Resident 8 ' s floor near the trash can, two feet from the bathroom door.
The World Health Organization (WHO) reported that roaches can carry pathogens (bacteria or virus) that cause a variety of diseases including gastroenteritis (with diarrhea, nausea, and vomiting).
This deficiency had the potential to affect all 116 residents in the facility if the residents consume contaminated food or touch contaminated surfaces.
Findings:
A review of Resident 8 ' s admission record indicated that the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic inflammatory [body ' s reaction to an irritant] lung disease that causes obstructed airflow from the lungs), hypertension (increase in blood pressure), and diabetes mellitus type II (high levels of sugar in the blood).
A review of Resident 8 ' s minimum data set (MDS- federally mandated assessment tool) indicated that the resident was cognitively intact. The resident was also independent on all care needs.
On 4/11/23 at 9:52 a.m., during an observation, a dead small roach was noted on the floor next to the trashcan not two feet from the bathroom door.
On 4/11/2023 at 9:55 a.m., Facility Administrator (FA), confirmed that it was a dead cockroach.
On 4/11/2023 at 10:06 a.m., during an interview, Certified Nurse Assistant 3 (CNA3) stated that she sees roaches, sometimes.
On 4/11/2023 at 12:41 p.m., during an interview, Housekeeping Supervisor (HS) stated that it was reported by nursing staff that they have seen roaches in one of the rooms. Per HS, the pest control company did not find any roaches in that room. HS stated that the pest control company treated the whole facility. HS stated that the pest control company comes every week of every month.
On 4/20/2023 at 9:46 a.m., during an interview with the Director of Nursing, roach infestation is an infection control concern.
A review of the facility ' s Pest Control policy, reviewed 4/2023, indicated a policy statement Our facility shall maintain an effective pest control program.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by not reporting the alleged ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by not reporting the alleged abuse to the State Survey Agency (SSA) within two hours after the allegation was made for one of three sampled residents (Resident 1).
On 3/5/2023, at 10 a.m., Resident 1 and Family Member (FM) reported an alleged resident-to-resident abuse but the allegation was not reported to the SSA until 2 p.m.
This deficient practice had the potential to place the residents at risk for abuse.
Findings:
A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 5/11/2021 with a readmission dated 8/1/2022, with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] or a kidney transplant to maintain life) and anemia (a condition in which the number of red blood cells [carry oxygen] are lower than normal).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 2/16/2023, indicated Resident 1 had intact cognition (thought process) and had the ability to make self-understood and understand others.
A review of Resident 1 ' s Change in Condition Evaluation dated 3/5/2023 and timed at 3 p.m. indicated Resident 1 ' s FM informed staff at 10 a.m. Resident 2 was scratched and hit by Resident 2.
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 5/1/2009 with a re-admission dated 1/12/2023, with diagnoses including vascular dementia (refers to changes to memory, thinking, and behavior) and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).
A review of Resident 2 ' s MDS dated [DATE], indicated Resident 2 had intact cognition and usually had the ability to make self-understood and understand others.
A review of Resident 2 ' s Change in Condition Evaluation dated 3/5/2023 at 2:51 p.m. indicated Resident 2 was combative, the doctor was notified on 3/5/2023 at 11 a.m. with recommendation to transfer resident to a general acute care hospital (GACH).
During an interview on 3/16/2023 at 2:48 p.m., Licensed Vocational Nurse (LVN 1) stated Resident 1 was screaming that Resident 2 had scratched her in her eye and pulled off her hat, LVN 1 stated during assessment of Resident 1 LVN 1 did not observe any injuries. LVN 1 stated she did not report Resident 1 ' s allegations of abuse, LVN 1 stated she should have reported to the Administrator within two hours of the incident occurring. LVN 1 stated she did not separate the resident and she should have, LVN 1 stated she placed Resident 1 at risk for further abuse.
During an interview on 3/16/2023 at 3:50 p.m., Registered Nurse Supervisor (RNS 1) stated at 10:30 a.m. FM stated Resident 2 had scratched Resident 1 in the eye and removed her hat. RNS 1 stated during assessment of Resident 1 there were no visible scratches on Resident 1. RNS 1 stated she did not report abuse within two hours to the Ombudsman Program (residents ' advocates) and to the SSA until around 2 p.m.
During an interview on 3/16/2023 at 4:25 p.m., the Director of Nursing (DON) stated facility ' s policy to report within two hours from the allegation made was not followed.
A review of facility ' s policy and procedures titled, Abuse Investigation and Reporting, last revised on 7/2017 indicated an alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but no later than two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury.
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and records review, the facility failed to ensure call light device was within reach for one of three sampled residents (Resident 2).
This deficient practice may resul...
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Based on observation, interview, and records review, the facility failed to ensure call light device was within reach for one of three sampled residents (Resident 2).
This deficient practice may result in the delay in care and not receiving assistance timely.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/13/2022 with diagnoses including urinary tract infection (UTI- when bacteria gets into your urine and travels up to your bladder), dysphagia (difficulty in swallowing), hypertension (uncontrolled elevated blood pressure) and dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities).
A review of Resident 2 ' s History and Physical (H&P), dated 9/14/2022, indicated the resident did not have capacity to understand and make decisions.
A review of Resident 2 ' s Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 12/16/2022, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required limited assistance for moving in bed, transferring to bed to chair, toilet use and dressing. Resident 2 was frequently incontinent (unable to control) of bladder and always continent for bowel functions.
A review of Resident 2 ' s Care Plan regarding at risk for fall, created on 11/27/2022 and revised on 12/21/2022, indicated the following interventions:
-Be sure resident ' s call light is within reach and encourage the resident to use it for assistance as needed.
-The resident needs a safe environment with even floors free from spills and /or clutter, adequate light, a working and reachable call light, the bed in low position at night, personal items within reach.
A review of Resident 2 ' s Care Plan regarding actual fall, created on 11/28/2022 and revised on 1/14/2023, indicated an intervention that call light is within reach at all times.
During a concurrent observation and interview on 2/1/2023, at 10:07 a.m., with Registered Nurse 2 (RN 2) inside Resident 2 ' s room, Resident 2 ' s call light was observed hanging on the wall above residents head. RN 2 stated Resident 2 cannot reach that far and placed the call light on his right hand above his abdomen. RN 2 stated call light should be within his reach.
During an interview on 2/1/2023 at 10:29 a.m., the Director of Nursing (DON) stated call light should be within reach.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to implement the care plan for fall for one of three sampled residents (Resident 2).
This deficient practice had the potential t...
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Based on observation, interview, and record review, the facility failed to implement the care plan for fall for one of three sampled residents (Resident 2).
This deficient practice had the potential to negatively affect Resident 2's physical well-being and place the resident at risk for injuries in case of a fall.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/13/2022 with diagnoses including urinary tract infection (UTI- when bacteria gets into your urine and travels up to your bladder), dysphagia (difficulty in swallowing), hypertension (uncontrolled elevated blood pressure) and dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities).
A review of Resident 2 ' s History and Physical (H&P), dated 9/14/2022, indicated the resident did not have capacity to understand and make decisions.
A review of Resident 2 ' s Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 12/16/2022, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required limited assistance for moving in bed, transferring to bed to chair, toilet use and dressing. Resident 2 was frequently incontinent (unable to control) of bladder and always continent for bowel functions.
A review of Resident 2 ' s Order Summary Report, dated 9/14/2022, indicated an order for bilateral landing pads by bedside and monitor for presence and placement to minimize injury every shift for fall precaution.
A review of Resident 2 ' s Care Plan on risk for fall, dated 9/14/2022 and revised on 12/21/2022, indicated an intervention for bilateral landing pads at beside. Monitor for presence and placement to minimize injury.
A review of Resident 2 ' s Medication Administration Record (MAR), dated 1/2023, indicated nurses were documenting that bilateral landing pads by bedside every shift.
During a concurrent observation and interview on 2/1/2023 at 10:07 a.m., with Registered Nurse 2 (RN 2) and inside Resident 2 ' s room, Resident 2 was observed in low bed, asleep with no landing pads on both sides of the bed. RN 2 stated resident does not have landing pads.
During an interview on 2/1/2023 at 10:29 a.m., the Director of Nursing (DON) stated Resident 2 is a fall risk and ambulate without calling for assistance. DON stated there should be a landing pad on both sides of the bed to prevent injury due to fall.
A review of facility ' s policy and procedure titled, Falls and Fall Risk, Managing, dated 3/2018, indicated, The staff with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of fall for each resident at risk or with history of fall.
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 F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) who was receiving Risperdal (medication used to treat mental and mood disorder) was asse...
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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) who was receiving Risperdal (medication used to treat mental and mood disorder) was assessed and monitored for its side effect.
This deficient practice placed Resident 2 at risk for side effects including headache, drowsiness, heart problems and trouble walking.
Findings:
A review of Resident 2 ' s admission Record indicated, the facility admitted the resident on 9/13/2022 with diagnoses including urinary tract infection (UTI- when bacteria gets into your urine and travels up to your bladder), dysphagia (difficulty in swallowing), hypertension (uncontrolled elevated blood pressure) and dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities).
A review of Resident 2 ' s History and Physical (H&P), dated 9/14/2022, indicated the resident did not have capacity to understand and make decisions.
A review of Resident 2 ' s Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 12/16/2022, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required limited assistance for moving in bed, transferring to bed to chair, toilet use and dressing. Resident 2 was frequently incontinent (unable to control) of bladder and always continent for bowel functions.
A review of Resident 2 ' s Order Summary Report, dated 1/26/2023, indicated an order for Risperdal (medication used to treat mental and mood disorder) tablet 0.25 milligram (mg-unit of measure) by mouth every 12 hours for disorientation (confusion or lack of understanding) for 14 days.
A review of Resident 2 ' s Medication Administration Record (MAR), dated 1/2023, indicated no monitoring for the side effect of Risperdal was documented.
A review of Resident 2 ' s Care Plan regarding the use of psychotropic medication (any medication that affects behavior, mood, thoughts, or perception) Risperdal related to behavior management, dated 9/14/2022, indicated, Administer psychotropic medications as ordered by the physician. Monitor for the side effects and effectiveness every shift.
Monitor/document/report any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia (movement disorder characterized by uncontrollable and repetitive movements of the face, and other parts of the body), extrapyramidal symptoms (EPS -movement disorders like shuffling gait, rigid muscles and shaking), frequent falls ).
During an interview on 2/1/2023 at 10:29 a.m., the Director of Nursing (DON) stated nurses should document monitoring for the side effects and effectiveness of Risperdal because it is an antipsychotic medication.
A review of facility ' s policy and procedure titled, Antipsychotic Medication Use, dated 12/2016, indicated, The staff will observe, document, and report to the Attending Physician information regarding the effectiveness or any interventions, including antipsychotic medications. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending Physician:
a. General: constipation, blurred vision, dry mouth, urinary retention, sedation.
b. Cardiovascular: orthostatic hypotension (low blood pressure after a change in position from siting to standing), arrythmias (irregular heartbeat)
c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain
d. Neurologic: Akathisia (restlessness), dystonia (muscle disorder that causes muscles to contract involuntarily, extrapyramidal effects, akinesia (loss of ability to move muscles), dyskinesia (involuntary movement of face and body), stroke (sudden interruption in the blood flow to the brain) or transient ischemic attack (TIA-mini-stroke).
Feb 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure that staffing information was posted per facility policy on 2/4/2023.
This deficient practice had the potential to res...
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Based on observation, interview, and record review, the facility failed to ensure that staffing information was posted per facility policy on 2/4/2023.
This deficient practice had the potential to result to actual staffing hours not readily accessible to the residents and visitors and possibly missed any insufficient nurse staffing.
Findings:
During an observation of the facility on 2/4/2023 at 11:04 a.m , observed nurse staffing hours posted in the lobby area, with no actual nursing hours.
During a concurrent interview with the Assistant Director of Nursing (ADON), on 2/4/2023 at 12:37 p.m., ADON stated and confirmed that the nurse staffing hours posting was not updated and posted per facility policy. ADON stated, even on the weekends, the staffing hours should be updated with the actual nursing hours daily to be able to see if they have a sufficient nursing hour for the day.
A review of facility ' s policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, revised July 2016, indicated within two hours of the beginning of each shift, the number of Licensed Nurses and the number of unlicensed nursing personnel directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) in a clean and readable format.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 observation, interview, and record review, the facility failed to follow its policy in reporting of a resident-to-resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy in reporting of a resident-to-resident verbal abuse altercation to the Local Law enforcement, Long-Term Care Ombudsman (an appointed official that investigates, reports, and helps settle complaints), and to the California Department of Public Health ([CDPH] licensing and certification division) affecting two of three sampled residents (Resident 1 and Resident 2).
This deficient practice placed Resident 1 and Resident 2 at an increased risk for potential emotional pain, physical harm, and further trauma associated with abuse.
Findings:
A review of Resident 1 ' s admission Record indicated an admission date of 3/12/2021 with the diagnoses including vascular dementia (brain damage due to loss of blood flow to brain), essential hypertension (high blood pressure), and transient ischemic attack (decreased oxygenation due to temporary loss of blood supply to the brain).
A record review of Resident 1's Minimum Data Set ([MDS] standardized assessment and screening tool), dated 3/16/2022, indicated that Resident 1 had moderate impairments with understanding questions, thought process, and decision-making tasks.
A review of Resident 2 ' s admission Record indicated an admission date of 12/13/2022 with the diagnoses including hemiplegia (muscle weakness to one side of the body) and hemiparesis (muscle weakness or partial loss of muscle movement affecting arms & legs) following cerebral infarction (a blockage of blood flow to the brain), muscle weakness, and history of falling.
A record review of Resident 2's MDS dated [DATE], indicated that Resident 2 is capable of understanding, answering questions, and able to have an intact thought process.
On 12/28/2022 at 12:50 p.m., during lunch observation, Resident 1 and Resident 2 were observed cursing (the use of foul or belittling language) at each other while in the same room.
On 12/28/2022 at 4:45 p.m., during an interview, Certified Nurse Assistant 1 (CNA 1) indicated that if abuse is witnessed, the staff are to separate the involved residents and stay to make sure no one gets injured. CNA 1 stated that all staff are mandated (legally responsible) reporters, and that reporting of abuse is done within two (2) hours to the Ombudsman, Law Enforcement, and to California Department of Public Health (CDPH). CNA 1 stated that the Administrator is the abuse coordinator of the facility, and that types of abuse include verbal abuse, negligence, physical abuse, financial abuse, sexual, and emotional abuse.
On 12/29/2022 at 5:07 p.m., during an interview, the Administrator (ADM) stated that a verbal abuse could be in the form of cursing or threatening. ADM stated that once an allegation is presented, ADM would immediately start investigation and separate the involved residents. ADM indicated that if there is an abuse and ADM is not made aware, this delays the investigation timeframe, risking the safety of the residents.
On 12/29/2022 at 5:26 p.m., during a phone interview in the presence of the ADM, Certified Nurse Assistant 2 (CNA 2) stated that during lunch time on 12/28/2022, Resident 2 was exiting the room when Resident 1 was blocking the exit door. Because of this, Resident 2 started cursing at Resident 1 and stated that Resident 1 was sexually attracted to the same sex. CNA 2 confirmed that both residents were cursing back at each other. In the presence of the ADM, CNA 2 was asked the question if this resident-to-resident altercation was reported to anyone, CNA 2 stated not reporting the altercation to the ADM due to forgetting.
On 2/13/2023 at 5:10 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that if the staff that happens to witness abuse does not inform the Charge Nurse, Director of Nursing, or Administrator, then the safety of the residents ' is compromised. LVN 1 stated that lack of reporting delays the investigation timeframe.
A review of the facility policy titled, Abuse Investigation and Reporting, with last revised date of 7/2017, indicated in the statement policy that, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported. The policy also stated, All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons: The State licensing/certification agency responsible for surveying/licensing the facility; the local/State Ombudsman; and Law enforcement officials.
Jan 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure two of seven sampled residents (Resident 1 and Resident 2) were treated with dignity and respect in accordance with th...
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Based on observation, interview, and record review, the facility failed to ensure two of seven sampled residents (Resident 1 and Resident 2) were treated with dignity and respect in accordance with the facility's policy and procedure.
a. Resident 1 expressed that wearing incontinent briefs was not her preference and stating it was demeaning and humiliating.
b. Failing to accommodate Resident 2 for more than 1 hour and 30 minutes, when resident requested to be transferred from bed to wheelchair.
These deficient practices resulted in the facility violating residents' rights to a dignified existence and placed the residents at risk for skin breakdown.
Findings:
a. During an observation and concurrent interview on 12/13/2022 at 6:11 p.m., Resident 1 was sitting in a wheelchair in her room. Resident 1 stated that she had to wear incontinent briefs at night because there was not enough staff to get her up and assist her to the restroom in the morning. The resident stated that wearing incontinent briefs was not her preference and it was demeaning and humiliating. The resident also stated that she had no choice but to wear incontinent briefs because she will end up wetting her bed waiting for help.
During an interview on 12/19/2022 at 11:21 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that some residents had to wait long because CNAs had more residents to care for due to less staff working.
A review of Resident 1's admission Record indicated that the facility initially admitted the resident on 10/13/2016 and readmitted the resident on 6/29/2020, with diagnoses including hemiplegia (paralysis of the muscles of the lower face, arm, and leg on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating and dressing), epilepsy (a group of disorders marked by problems in the normal functioning of the brain that can produce unusual body movements, a loss of consciousness as well as mental problems or problems with the senses), and hypothyroidism (when a thyroid glands doesn't make enough thyroid hormones).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/7/2022, indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. It indicated the resident required extensive assistance on transfers, toilet use, and personal hygiene. The MDS also indicated the resident was always continent in urine and bowel.
A review of Resident 1's care plan dated 7/20/2022, indicated the resident was at risk for bladder and bowel incontinence related to overactive bladder, impaired mobility, self-care deficits, and required assistance in toileting use and activities of daily living (ADL). The care plan also indicated resident's goal of remaining free from skin breakdown and brief use through the review date.
During an interview on 12/19/2022 at 3:11 p.m. with the Director of Nursing (DON), the DON stated that residents should not wear incontinent briefs if it was not the residents' preference. The DON stated that residents' preferences should be documented in the resident's medical records.
During a concurrent interview and record review on 12/19/2022 at 3:58 p.m. with Registered Nurse 1 (RN 1), RN 1 stated that Resident 1's MDS indicated the resident was always continent in bowel and bladder. RN 1 also stated that bowel and bladder assessment on Resident 1 was done on 10/20/2022 which indicated the resident was continent of urine. A review of Resident 1's ADL documentation on 12/13/2022 and 12/14/2022 on the 7-3 shift, indicated the resident was incontinent on bladder. RN 1 stated that the staff are documenting incontinent when the resident was on incontinent brief.
b. During an interview on 12/13/2022 at 5:55 p.m. with Resident 2, Resident 2 stated that he was not getting assistance out of bed to his wheelchair until 11 a.m. and had to wait until someone gets to me.
During an observation and concurrent interview on 12/19/2022 at 10:43 a.m., Resident 2's call light was on. Resident 2 stated that he was going to ask the staff when he will get help out of bed. Resident 2 stated that he has been waiting since 9 a.m. for a Certified Nurse Assistant (CNA) to return. Resident 2 stated that sometimes it makes him mad because he was not being cared for timely.
During an interview on 12/19/2022 at 11:21 a.m. with CNA 2, CNA 2 stated that some residents had to wait for a long time because CNAs had more residents to care for due to less staff working.
A review of Resident 2's admission Record indicated the facility initially admitted the resident on 9/2/2020 and readmitted the resident on 12/17/2021, with diagnoses including type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and hypertension (a condition in which the blood vessels have persistently rapid pressure).
A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/7/2022, indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. It also indicated the resident required limited assistance with one person assist on transfers.
A review of Resident 2's care plan dated 12/19/2022, indicated the resident had ADL self-care performance deficit related to impaired balance, limited mobility, and pain on left hip. The intervention indicated the resident requires extensive assistance by one staff to move between surfaces.
During an interview on 12/19/2022 at 3:11 p.m. with the Director of Nursing (DON), the DON stated the residents should be out of bed before breakfast or before 8 a.m. or 9 a.m. to prevent residents' conditions to decline.
A review of the facility's policy and procedure titled Quality of Life – Dignity revised on 2/2020, indicated that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. The policy indicated that demeaning practices and standards of care that compromise dignity are prohibited, staff are expected to promote dignity and assist residents.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of seven sampled residents (Residen...
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Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of seven sampled residents (Resident 1) by failing to ensure Resident 1's care plan reflected the resident's preference not to wear incontinent briefs. Resident 1 was continent of bowel and bladder functions.
This deficient practice had placed Resident 1 at risk for not receiving the necessary services and assistance that can result in urinary tract infection ((TI – when bacteria goes into the urine and travels up to the bladder) and skin breakdown (damage to the skin surface caused by friction, shear, moisture and/or pressure). This also resulted in the resident feeling demeaned and humiliated.
Findings:
A review of Resident 1's admission Record indicated that the facility initially admitted the resident on 10/13/2016 and readmitted the resident on 6/29/2020, with diagnoses including hemiplegia (paralysis of the muscles of the lower face, arm, and leg on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating and dressing), epilepsy (a group of disorders marked by problems in the normal functioning of the brain that can produce unusual body movements, a loss of consciousness as well as mental problems or problems with the senses), and hypothyroidism (when a thyroid gland doesn't make enough thyroid hormones).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/7/2022, indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. It indicated the resident required extensive assistance on transfers, toilet use, and personal hygiene. The MDS also indicated the resident was always continent in urine and bowel.
A review of Resident 1's care plan dated 7/20/2022, indicated the resident was at risk for bladder and bowel incontinence related to overactive bladder (causes a frequent and sudden urge to urinate that may be difficult to control), impaired mobility, self-care deficits, and required assistance in toileting use and activities of daily living (ADL). The care plan also indicated resident's goal of remaining free from skin breakdown and brief use through the review date.
During an interview on 12/13/2022 at 6:11 p.m. with Resident 1, Resident 1 stated that she had to wear incontinent briefs (disposable briefs) at night because there was not enough staff to get her up and assist her to the restroom in the morning. The resident stated that wearing incontinent briefs was not her preference and it was demeaning and humiliating . The resident also stated that she had no choice but to wear incontinent briefs because she will end up wetting her bed while waiting for help.
During an interview on 12/19/2022 at 3:11 p.m. with the Director of Nursing (DON), the DON stated that residents should not wear incontinent briefs if it is not the resident's preference. The DON stated that resident's preference should be documented in the resident's medical records .
During a concurrent interview and record review on 12/19/2022 at 3:58 p.m. with Registered Nurse 1 (RN 1), RN 1 stated that Resident 1's MDS indicated the resident was always continent in bowel and bladder. RN 1 stated that bowel and bladder assessment was done on 10/20/2022 which indicated the resident was continent of urine. RN 1 stated that care plans are individualized and person-centered. A concurrent record review of Resident 1's care plan intervention indicated the resident uses disposable briefs and to check every shift as required for incontinence. RN 1 stated that if the resident does not prefer to wear incontinent briefs or disposable briefs but included in the care plan, then the care plan was not individualized and person-centered.
A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, revised in 12/2016, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident; the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide necessary services and assistance to maintain bladder continence on one of seven sampled residents (Resident 1) by placing an incon...
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Based on interview and record review, the facility failed to provide necessary services and assistance to maintain bladder continence on one of seven sampled residents (Resident 1) by placing an incontinent brief on a resident who was continent of bladder.
This deficient practice had placed Resident 1 at risk for urinary tract infection (UTI – when bacteria goes into the urine and travels up to the bladder) and skin breakdown (damage to the skin surface caused by friction, shear, moisture and/or pressure). This also resulted in the resident feeling demeaned and humiliated.
Findings:
A review of Resident 1's admission Record indicated that the facility initially admitted the resident on 10/13/2016 and readmitted the resident on 6/29/2020, with diagnoses including hemiplegia (paralysis of the muscles of the lower face, arm, and leg on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating and dressing), epilepsy (a group of disorders marked by problems in the normal functioning of the brain that can produce unusual body movements, a loss of consciousness as well as mental problems or problems with the senses), and hypothyroidism (when a thyroid gland doesn't make enough thyroid hormones).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/7/2022, indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. It indicated the resident required extensive assistance on transfers, toilet use, and personal hygiene. The MDS also indicated the resident was always continent in urine and bowel.
A review of Resident 1's care plan dated 7/20/2022, indicated the resident was at risk for bladder and bowel incontinence related to overactive bladder (causes a frequent and sudden urge to urinate that may be difficult to control), impaired mobility, self-care deficits, and required assistance in toileting use and activities of daily living (ADL). The care plan also indicated resident's goal of remaining free from skin breakdown and brief use through the review date.
During an interview on 12/13/2022 at 6:11 p.m. with Resident 1, Resident 1 stated that she had to wear incontinent briefs at night because there was not enough staff to get her up and assist her to the restroom in the morning. The resident stated that wearing incontinent briefs was not her preference and it was demeaning and humiliating . The resident also stated that she had no choice but to wear incontinent briefs because she will end up wetting her bed while waiting for help.
During an interview on 1219/2022 at 11:21 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that some residents had to wait long because CNAs have more residents to care for due to less staff working.
During an interview on 12/19/2022 at 3:11 p.m. with the Director of Nursing (DON), the DON stated that residents should not wear incontinent briefs if it is not the resident's preference. The DON stated that resident's preference should be documented in the resident's medical records .
During a concurrent interview and record review on 12/19/2022 at 3:58 p.m. with Registered Nurse 1 (RN 1), RN 1 stated that Resident 1's MDS indicated the resident was always continent in bowel and bladder. RN 1 stated that bowel and bladder assessment was done on 10/20/2022 which indicated the resident was continent of urine. A concurrent record review of Resident 1's care plan intervention indicated the resident uses disposable briefs and check every shift as required for incontinence.
A review of the facility's policy and procedure titled Urinary Continence and Incontinence – Assessment and Management, revised on 09/2010, indicated the physician and staff will provide appropriate services and treatment to help residents restore and improve bladder function. It also indicated that as part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence such as type and frequency of physical assistance necessary for the resident to access the toilet, commode, or urinal.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the staffing information was complete and was not missing information for the dates 10/1/2022 to 12/22/2022 by failing to document a...
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Based on interview and record review, the facility failed to ensure the staffing information was complete and was not missing information for the dates 10/1/2022 to 12/22/2022 by failing to document actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift.
This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility.
Findings:
A review of the facility's Census and Direct Care Services Hours Per Patient Day (DHPPD - refers to the actual hours of work performed per patient day by a direct caregiver) dated 10/1/2022 to 12/22/2022, indicated there were no DHPPD for the dates 12/3/2022, 12/4/2022, 12/5/2022, 12/10/2022, and 12/11/2022. It also indicated the DHPPD dated 10/25/2022 to 10/31/2022, 12/1/2022, 12/2/2022, 12/6/2022, 12/7/2022, 12/8/2022, 12/9/2022, and 12/12/2022 were incomplete.
During an interview on 12/19/2022 at 1:15 p.m. with the Director of Staff Development (DSD), the DSD stated she was responsible for ensuring the staff posting was complete and posted daily. The DSD stated staff posting should be completed and posted daily with the Director of Nursing (DON) or designee's signature so that residents, family, and staff are aware of the facility census and staff hours of service per resident.
During an interview on 12/19/2022 at 3:11 p.m. with the DON, the DON stated the DHPPD should be posted daily and updated one hour after each shift so that the residents, their family and staff are aware the facility has adequate staff to care for the residents.
A review of the facility's policy and procedure titled, Posting Direct Care Daily Staffing Numbers, revised on July 2016, indicated it is the policy of the facility to post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. The policy indicated shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The posting will include the name of the facility, the date for which the information is posted, resident census at the beginning of the shift, twenty-four hour shift schedule, type and category of nursing staff working, actual time worked for each category and type of nursing staff, and total number of licensed and non-licensed nursing staff working for the posted shift.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is ...
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Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for three of seven sampled residents (Residents 3, 6, and 7), by failing to:
a. Ensure that Activity Assistant's (AA) face shield or goggles were always worn within the facility and when providing care to Resident 3.
b. Ensure Certified Nurse Assistant 1's (CNA 1) personal protective equipment (PPE – equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was worn before entering the enhanced barrier precaution (EBP – an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) room and hand hygiene was performed before and after touching Resident 6 and 7's food trays. CNA 1 did not wear any gloves and gown before touching Resident 6 followed by touching Resident 7's food tray and delivering it to the resident.
c. Ensure that transportation company personnel wore N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) before entering the facility.
These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19.
Findings:
a. A review of Resident 3's admission Record indicated the facility admitted the resident on 10/8/2012 and readmitted the resident on 7/1/2020 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body), systemic lupus erythematosus (an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs), and epilepsy (a group of disorders marked by problems in the normal functioning of the brain that can produce seizures, unusual body movements, a loss of consciousness as well as mental problems or problems with the senses).
A review of Resident 3's History and Physical, dated 11/29/2021, indicated the resident had the capacity to understand and make decisions.
During an observation and concurrent interview on 12/13/2022 at 4:26 p.m. Activity Assistant (AA) came out of Resident 3's room without face shield or goggles. AA stated that her goggles was left in the office. AA stated that infection could spread to other resident and staff if proper PPE such as goggles or face shields were not worn.
During an interview on 12/19/2022 at 1:50 p.m. with Infection Preventionist Nurse (IPN), IPN stated that goggles or face shields should be worn in resident care areas. IPN stated the purpose of wearing proper PPE is to protect the staff and residents and prevent spread of infection.
During an interview on 12/19/2022 at 3:11 p.m. with the Director of Nursing (DON), the DON stated that N95 mask and goggles or face shield are worn while inside the facility at all times.
A review of the facility's policy and procedure titled Personal Protective Equipment , revised on 8/2018, indicated visitors and residents who are asked to comply with transmission-based precautions are educated on the proper use of PPE and provided with equipment at no charge.
A review of the facility's policy and procedure titled, Infection Prevention and Control Program, revised on 10/2018, indicated that the facility establishes and maintains an infection control program designed to provide a safe, sanitary, ad comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements.
b. A review of Resident 6's admission Record indicated the facility admitted the resident on 5/8/2021 with diagnoses including type 2 diabetes mellitus (a condition that affects the way the body processes the blood sugar), hypertension (a blood pressure that is higher than normal), and dementia (the impaired ability to remember, think or make decisions that interferes with everyday activities).
A review of Resident 6's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 11/11/2022, indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired.
A review of the list of residents on EBP indicated that Resident 6 was on the EBP list for multidrug resistant organisms (MDRO – bacteria that is resistant with more than one antibiotic).
A review of Resident 7's admission Record indicated the facility admitted the resident on 8/11/2015 and readmitted the resident on 8/21/2021 with diagnoses including pulmonary hypertension (happens when the pressure in the blood vessels leading from the heart to the lungs is too high), hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body).
A review of Resident 7's History and Physical, dated 9/9/2022, indicated the resident had the capacity to understand and make decisions.
During an observation on 12/13/2022 at 5:35 p.m., observed Certified Nursing Assistant 1 (CNA) wheeling Resident 6 back to the resident's room. CNA 1 came out of the room without performing hand washing or use of hand sanitizer and proceeded to the food cart, took a tray, and went back inside Resident 6's room. CNA 1 came out of Resident 6's room without performing hand washing or use of hand sanitizer, took a tray from the food cart located in between Resident 6 and Resident 7's room and entered Resident 7's room. CNA 1 exited resident 7's room without performing hand washing or use of hand sanitizer. Also observed CNA 1's N95 to be missing the metal on the nose bridge of the mask and the top strap of the N95 mask was on CNA 1's neck area instead of the head.
During an interview on 12/13/2022 at 5:59 p.m. with CNA 1, CNA 1 stated that she should have used the hand sanitizer before and after resident care to prevent spread of infection from one resident to another. CNA 1 also stated that she took the metal part of the N95 located at the nose bridge of the mask because it creates a blister on her nose. CNA 1 stated that tampering with and not wearing the N95 mask properly will lose the seal and will be ineffective in protecting her.
During an interview on 12/19/2022 at 1:50 p.m. with Infection Preventionist Nurse (IPN), IPN stated that handwashing and use of hand sanitizers are done before and after resident care. IPN also stated that PPEs should not be tampered with to prevent losing the PPE's seal and effectiveness. The IPN stated the purpose of wearing proper PPE is to protect the staff and residents and prevent spread of infection.
During an interview on 12/19/2022 at 3:11 p.m. with the Director of Nursing (DON), the DON stated hand washing or use of hand sanitizers are done before and after resident care. The DON also stated that N95 mask and other PPEs should not be tampered with to prevent losing the seal and effectiveness in preventing spread of infection. The DON stated that IPN should be informed for any N95 fitting concerns.
A review of the facility's policy and procedure titled Handwashing/Hand Hygiene , revised 8/2019, indicated that facility considers hand hygiene the primary means to prevent the spread of infections All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents, before and after eating or handling food, and before and after assisting a resident with meals.
A review of the facility's policy and procedure titled Personal Protective Equipment , revised on 8/2018, indicated visitors and residents who are asked to comply with transmission-based precautions are educated on the proper use of PPE and provided with equipment at no charge.
A review of the facility's policy and procedure titled, Infection Prevention and Control Program, revised on 10/2018, indicated that the facility establishes and maintains an infection control program designed to provide a safe, sanitary, ad comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements.
c. During an observation on 12/19/2022 at 11:35 a.m., a transportation company employee was in the nurses' station without a N95 mask and goggles or face shield. The transportation company employee stated he was picking up a resident for an appointment and he was screened in the lobby but was not offered a mask at the lobby.
During an interview on 12/19/2022 at 11:40 a.m. with receptionist (RC), RC stated that transportation company employees are screened for COVID-19 and temperature are taken but not logged in the book. RC stated that all person entering the facility should wear a mask.
During an interview on 12/19/2022 at 3:11 p.m. with the Director of Nursing (DON), the DON stated that all staff and visitors including transportation company employees are required to wear N95 mask which is available at the lobby.
A review of the facility's policy and procedure titled Personal Protective Equipment , revised on 8/2018, indicated visitors and residents who are asked to comply with transmission-based precautions are educated on the proper use of PPE and provided with equipment at no charge.
A review of the facility's policy and procedure titled, Infection Prevention and Control Program, revised on 10/2018, indicated that the facility establishes and maintains an infection control program designed to provide a safe, sanitary, ad comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements.
Nov 2022
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that medications are administered in a timely ...
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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 medications are administered in a timely manner in accordance with the prescriber ' s order and facility policy and procedure for one of three sampled residents (Resident 1) by failing to administer Resident 1 ' s medications on time.
This deficient practice placed Resident 1 at risk for inadequate blood pressure management which can cause hypotension (low blood pressure) and irregular heartbeat. This deficient practice also placed the resident at risk for inadequate blood sugar management which can cause hypoglycemia (low blood sugar).
Findings:
A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of type 2 diabetes mellitus (DM2 - a condition that affects the way the body processes blood sugar) with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes), epilepsy (a group of disorders marked by problems in the normal functioning of the brain that can produce seizures, unusual body movements, a loss of consciousness as well as mental problems or problems with the senses), and hypertension (high blood pressure).
A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and screening tool), dated 11/4/2022, indicated that Resident 1 ' s cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making were intact.
On 11/18/2022 at 11:22 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed preparing medications in front of Resident 1 ' s room. LVN 1 was observed putting one cranberry pill, one stool softener pill, one magnesium oxide pill, one senna pill, and one vitamin D3 pill in a medicine cup. A concurrent interview with LVN 1 stated the medications prepared are scheduled for 9 a.m.
A review of Resident 1 ' s Order Summary Report dated 11/18/2022, indicated the following medication orders:
1. Metformin HCL tablet 500 milligrams (mg) give 1 tablet by mouth two time a day for diabetes mellitus (DM).
2. Humulin N suspension 100 unit/milliliter (ml) inject 10 unit subcutaneously in the morning for DM2.
A review of Resident 1 ' s Medication Administration Record (MAR), indicated that the resident received Novolin R (short-acting insulin) 4 units subcutaneously on 11/18/2022 at 6:30 a.m. for a blood sugar level of 233 mg / deciliter (dL) and the resident confirmed that she ate breakfast right after the medication was administered.
A review of Resident 1 ' s Medication Admin Audit Report, indicated that the Metformin HCL tablet 500 mg was scheduled for 7:30 a.m. but was administered at 11:38 a.m. and the Humulin N suspension 10 units subcutaneously was scheduled for 7:30 a.m. but was administered at 11:44 a.m.
A review of Resident 1 ' s care plan (CP), revised on 02/11/2022, indicated the resident was at risk for hypoglycemia/ hyperglycemia (high blood sugar) and the resident would receive Humulin N suspension 10 units subcutaneously in the morning for DM.
During an interview on 11/21/2022 at 11:35 a.m., LVN 1 stated that medications scheduled for 9 a.m. should be given by 10 a.m. and confirmed that medications for Resident 1 was given more than one hour after the scheduled time. LVN 1 stated that medications given late can negatively affect the residents medical condition such as hypoglycemia.
During an interview on 11/21/2022 at 1:07 p.m., the Director of Nursing (DON) stated that medications are given either 1 hour before or 1 hour after the scheduled time. DON stated that medications administered after the one hour are considered late administration. A concurrent record review of Resident 1 ' s Medication Admin Audit Report, indicated that multiple medications were administered late.
A review of the facility ' s policy and procedure titled Administering Medications, revised on 4/2019, indicated that medications are administered in a safe and timely manner, and as prescribed. The policy also indicated that medications are administered in accordance with prescriber orders including any required time frame. The policy also indicated that medications are administered within one hour of their prescribed time, unless otherwise specified.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of quality for two of thr...
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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 meet professional standards of quality for two of three sampled residents (Resident 1 and Resident 2) by failing to administer Residents 1 and 2's medications on time.
This deficient practice placed the Residents 1 and 2 at risk for inadequate blood pressure management which can cause hypotension (low blood pressure) and irregular heartbeat, inadequate blood sugar management which can cause hypoglycemia (low blood sugar), and other unintended complications.
Findings:
a. A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of type 2 diabetes mellitus (DM2 - a condition that affects the way the body processes blood sugar) with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes), epilepsy (a group of disorders marked by problems in the normal functioning of the brain that can produce seizures, unusual body movements, a loss of consciousness as well as mental problems or problems with the senses), and hypertension (high blood pressure).
A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and screening tool), dated 11/4/2022, indicated Resident 1 ' s cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making were intact.
On 11/18/2022 at 11:22 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed preparing medications in front of Resident 1 ' s room. LVN 1 was observed putting one cranberry pill (rich in antioxidants that may help to reduce the frequency of kidney infections, promote heart health, and boost immune system), one stool softener pill, one magnesium oxide pill (mineral supplement used to prevent and treat low amounts of magnesium in the blood and to treat symptoms of too much stomach acid such as stomach upset, heartburn, and acid indigestion), one senna pill (laxative used to treat constipation), and one vitamin D3 pill (a vitamin that helps your body absorb calcium and phosphorus and is essential in maintaining a healthy immune system) in a medicine cup. A concurrent interview with LVN 1 stated the medications prepared were scheduled for 9 a.m.
A review of Resident 1 ' s Order Summary Report, dated 11/18/2022, indicated the following medication orders:
1. Metformin HCL (medication used to control blood sugar) tablet 500 milligrams (mg, unit of measurement) give 1 tablet by mouth two time a day for diabetes mellitus (DM).
2. Humulin N suspension (a type of insulin used to control blood sugar over many hours throughout the day)100 unit/milliliter (ml, unit of measurement) inject 10 unit subcutaneously (under all the layers of the skin) in the morning for DM2.
3. Cranberry capsule 425 mg by mouth two times a day for supplement.
4. Docusate Sodium (used to treat constipation) capsule 200 mg orally one time a day for stool management.
5. Magnesium Oxide tablet 400 mg give 1 tablet by mouth two time a day for supplement.
6. Senna tablet 8.6 mg give 1 tablet orally one time a day for stool management.
7. Vitamin D3 tablet 25 mg give 2 tablets by mouth one time a day for supplement.
8.Artificial tears solution instill 1 drop in both eyes two times a day for dry eyes syndrome.
9. Prostat SF (a ready-to-drink medical food providing 15 grams of hydrolyzed collagen protein and 100 calories per 1 fluid ounce) 30 ml PO (by mouth) two times a day for supplement.
10. Cordarone (used to treat and prevent an irregular heartbeat) 400 mg tablet PO QD (daily)
11. Neurontin capsule 100 mg give 2 capsules by mouth two time a day for diabetic neuropathy.
12. Losartan Potassium tablet 25 mg give 1 tablet by mouth one time a day for HTN (hypertension).
13. Risperidone tablet 1 mg give 1 tablet by mouth in the morning for schizo paranoia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly).
14. Potassium tablet give 20 mEq (milliequivalent) orally two time a day for hypokalemia (a lower than normal potassium level in the blood).
15. Depakene solution 250 mg /5ml give 250 mg by mouth two times a day for seizure disorder.
16. Tapazole tablet 5 mg give 1 tablet by mouth one time a day for thyrotoxicosis (a condition in which a person has too much thyroid hormone in the body).
17. Diclofenac sodium gel 1% apply 2 grams to both knees topically (on the surface of the body) four times a day for knee pain.
18. Geri-Mucil powder 68% give 1 tsp by mouth one time a day for constipation.
A review of Resident 1 ' s Medication Administration Record (MAR), indicated that the resident received Novolin R (short-acting insulin) 4 units subcutaneously on 11/18/2022 at 6:30 a.m. for a blood sugar level of 233 mg/deciliter (dL, a unit of measurement) and Resident 1 confirmed that she ate breakfast right after the medication was administered.
A review of Resident 1 ' s Medication Admin Audit Report, indicated that the Metformin HCL tablet 500 mg was scheduled for 7:30 a.m. but was administered at 11:38 a.m. and the Humulin N suspension 10 units subcutaneously was scheduled for 7:30 a.m. but was administered at 11:44 a.m. The other medications listed above were administered more than one hour after scheduled time.
A review of Resident 1 ' s care plan (CP), revised on 2/11/2022, indicated the resident was at risk for hypoglycemia/ hyperglycemia (high blood sugar) and the resident would receive Humulin N suspension 10 units subcutaneously in the morning for DM. Resident 1 ' s CP also indicated that the resident has hyperthyroidism (a condition that occurs when the thyroid gland makes more thyroid hormone than the body needs) related to thyrotoxicosis. The CP indicated Resident 1 would be given Tapazole tablet 5 mg one tablet by mouth two times a day for thyrotoxicosis. The CP also indicated that the resident had seizure disorder/epilepsy and resident would be given depakene solution 250 mg by mouth two times a day for seizure disorder.
During an interview on 11/21/2022 at 11:35 a.m., LVN 1 stated that medications scheduled for 9 a.m. should be given by 10 a.m. and confirmed that medications for Resident 1 was given more than one hour after the scheduled time. LVN 1 stated that medications given late can negatively affect the residents medical condition such as hypoglycemia.
During an interview on 11/21/2022 at 1:07 p.m., the Director of Nursing (DON) stated that medications are given either 1 hour before or 1 hour after the scheduled time. DON stated that medications administered after the one hour are considered late administration. A concurrent record review of Resident 1 ' s Medication Admin Audit Report, indicated that multiple medications were administered late.
b. A review of Resident 2 ' s admission Record indicated that the resident was admitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), hypertension (high blood pressure), and benign prostatic hyperplasia (BPH - a condition in which an overgrowth of prostate tissue blocking the flow of urine).
A review of Resident 2 ' s Minimum Data Set (MDS- a standardized assessment and screening tool), dated 11/4/2022, indicated that Resident 2 ' s cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making is intact.
A review of Resident 2 ' s Order Summary Report dated 11/18/2022, indicated the following medication orders:
1. Aspirin tablet chewable 81 mg give 1 tablet by mouth one time a day for myocardial infarct (MI- when one or more areas of the heart muscle don ' t get enough oxygen) and cerebrovascular accident (CVA- a loss of blood flow to part of the brain which damages brain tissue) prophylaxis.
2. Cozaar tablet 50 mg give one tablet by mouth one time a day for HTN.
3. Docusate sodium capsule 100 mg give one capsule by mouth one time a day for bowel management.
4. Flomax capsule 0.4 mg give one capsule by mouth one time a day for BPH.
5. Fluticasone-Salmeterol Aerosol powder breath activated 500-50 micrograms (mcg) one puff inhale orally two times a day for COPD exacerbation.
6. Pamelor capsule 10 mg give one capsule by mouth one time a day for depression.
7. Tiotropium bromide monohydrate capsule 18 mcg one puff inhale orally one time a day for COPD prophylaxis.
A review of Resident 2 ' s Medication Admin Audit Report, dated 11/21/2022, indicated the resident received his 9 a.m. medications more than one hour from the schedule time.
During an interview on 11/21/2022 at 1:07 p.m., the Director of Nursing (DON) stated that medications are given either 1 hour before or 1 hour after the scheduled time. DON stated that medications administered after the one hour are considered late administration. A concurrent record review of Resident 2 ' s Medication Admin Audit Report, indicated that multiple medications were administered late.
A review of the facility ' s policy and procedure titled Administering Medications, revised on 4/2019, indicated that medications are administered in a safe and timely manner, and as prescribed. The policy also indicated that medications are administered in accordance with prescriber orders including any required time frame. The policy also indicated that medications are administered within one hour of their prescribed time, unless otherwise specified.
Oct 2022
17 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safely transfer one of six sampled residents (Resident 92) from bed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safely transfer one of six sampled residents (Resident 92) from bed to wheelchair using the sit-to-stand lift (a mechanical device that helps lift a resident to rise from a seated position) with one-person staff assistance instead of the recommended two-person staff assistance (needing the help of two trained caregivers for patients who are too weak, too unsteady or otherwise unable to move themselves safely) according to the equipment's manual and Resident 92's plan of care. On 9/9/2022 at 10:50 a.m., Certified Nursing Assistant 1 (CNA 1), with no help from another staff, assisted Resident 92 to transfer from bed to wheelchair using the sit-to-stand lift. While on the sit-to-stand machine during transfer from bed to wheelchair, Resident 92 fainted, fell, and hit his head on the floor.
This deficient practice resulted to facility transferring Resident 92 to General Acute Care Hospital 1 (GACH 1) on 9/9/2022 at 11:35 a.m. for further treatment and evaluation. Resident 92 suffered a right head subdural hematoma (a type of bleed inside the head that occurs within the skull but outside the actual brain tissue, usually caused by a head injury strong enough to burst blood vessels) and underwent a right hemicraniectomy (a surgical procedure where a large flap of the skull is removed so brain swelling can be relieved inside the skull) for the removal of the subdural hematoma.
Findings:
A review of Resident 92's Face Sheet (admission Record) indicated the facility admitted the resident on 8/5/2020 and re-admitted on [DATE] with diagnoses that included thrombosis (a blood clot that reduces blood flow) of deep veins of right lower extremity (the right leg), embolism (obstruction of an artery by a blood clot), and traumatic subdural hemorrhage (also known as a subdural hematoma caused by trauma).
A review of Resident 92's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/10/2022, indicated Resident 92 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 92 required two-person extensive with bed mobility, transfer, locomotion on unit (how resident moves between locations in his/her room in a wheelchair), and locomotion off unit (how a resident moves to and returns from off-unit locations such as areas set aside for dining, activities or treatments).
A review of Resident 92's Change of Condition Form (COC, a sudden clinical change from a patient's baseline in physical, cognitive, or behavioral functions), dated 9/9/2022, indicated that on 9/9/2022, during the morning shift, Resident 92 passed out while on the sit-to-stand machine during transfer from bed to wheelchair. The COC indicated the facility transferred Resident 92 to GACH 1.
A review of Resident 92's Fall Risk Assessment, dated 8/10/2022, indicated Resident 92's risk for fall was moderate.
A review of Resident 92's care plan for Risk for Falls, initiated on 8/6/2022, indicated Resident 92 was at risk for fall. The care plan indicated an intervention, initiated on 10/18/2022, for staff to use a mechanical lift (Hoyer or total body lift, a mechanical device to transfer a resident who is unable to move himself or help in moving in any way) for transfer with two-person assistance.
A review of Resident 92's care plan for Activities of Daily Living (ADL, fundamental skills a person needs for self-care, such as combing hair and brushing teeth), dated 8/19/2022, indicated an intervention, initiated on 8/19/2022, that Resident 92 requires staff assistance to move between surfaces and staff may use the sit-to-stand machine with two-person assistance.
A review of Resident 92's GACH 1 Computed Tomography (CT, a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) notes of the head, dated 9/9/2022, indicated Resident 92 suffered a right head subdural hematoma.
A review of Resident 92's GACH 1 Operative Notes, dated 9/9/2022, indicated Resident 92 had a large right subdural hematoma. The Operative Notes indicated Resident 92 was immediately brought to the OR within one hour of arrival at GACH 1 and underwent a right hemicraniectomy for evacuation (removal) of the subdural hematoma. The Operative Notes indicated that after the operation, Resident 92 was kept intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into the trachea [airway/windpipe] so that air can get through) and brought in stable (not deteriorating in health after an operation) but critical condition (very sick or injured and likely to die) to GACH 1's Intensive Care Unit (ICU, a department of a hospital in which patients who are dangerously ill are kept under constant observation).
A review of Resident 92's Interdisciplinary Team (IDT, a group of professionals from various disciplines [such as nursing, nutrition, physical therapy] who work together to address a resident's physical and psychological needs) Review Note, dated 9/21/2022, indicated Resident 92 had a fall incident on 9/9/2022 at approximately 10:50 a.m. CNA 1 reported to Licensed Vocational Nurse 1 (LVN 1) that Resident 92 passed out during transfer from bed to wheelchair using the sit-to-stand machine. The IDT note indicated LVN 1 saw Resident 92 lying on the floor, passed out, and LVN 1 called Resident 92's name, but Resident 92 did not respond for five to ten seconds. The IDT note indicated Resident 92's blood pressure (the pressure of circulating blood against the walls of blood vessels) was 90/67 millimeters of Mercury (mmHg, a unit of measure, the normal blood pressure being approximately 120/80 mmHg; the upper number being the systolic blood pressure which is the pressure in the arteries when the heart beats and the lower number, the diastolic, which is the pressure in the arteries when the heart rests between beats). The IDT note indicated the paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) were called, Resident 92 was given oxygen at 2 liters per minute (L/min, a unit of measure) on a nasal canula (a tube to provide additional oxygen to a resident), and Resident 92 left the facility to go to GACH 1 on 9/9/2022 at 11:35 a.m.
A review of Resident 92's IDT Review Note, dated 10/18/2022, indicated the investigation report related to the fall concluded that CNA 1 used the sit-to-stand machine with no assistance. The Note indicated an in-service was done for CNA 1 in which the proper use of the sit to stand lift is a two-person assistance during transfer.
A review of Resident 92's Witness Statement for Investigation, dated 10/14/2022, indicated Resident 92 stated CNA 1 transferred him from bed to wheelchair using the sit-to-stand machine. The Witness Statement indicated Resident 92 stated the machine was slow and he lost consciousness as CNA 1 was putting him to the wheelchair and stated he tried hard to hold onto the machine. The Witness Statement indicated Resident 92 stated CNA 1 left the room to go call for help but came back right away. The Witness Statement indicated Resident 92 stated he was still holding onto the machine and CNA 1 was trying to help him to the floor and he felt he hit his head on the floor.
A review of CNA 1's Witness Statement for Investigation, dated 10/14/2022, indicated CNA 1 stated he prepared Resident 92 for transfer after cleaning and changing Resident 92's clothes. The Witness Statement indicated CNA 1 stated he used the sit-to-stand machine to transfer Resident 92 and asked many times Resident 92 was ok and ready for transfer to which Resident 92 responded yes all the time. The Witness Statement indicated CNA 1 stated that while transferring Resident 92, Resident 92 suddenly fainted, and CNA 1 assisted Resident 92 fall on the floor.
During an interview on 10/25/2022 at 12:47 p.m., Resident 92 stated CNA 1 was his CNA on 9/9/2022, the day of his fall. Resident 92 stated CNA 1 had no assistance (in using the sit-to-stand lift) from another staff and that he (Resident 92) fell. Resident 92 stated he hit his head on the floor and, as a result, had to go to the hospital.
During an interview on 10/26/2022 at 4:33 p.m., the Director of Nursing (DON) stated CNA 1 used the sit-to-stand lift to move Resident 92 from bed to wheelchair. The DON stated CNA 1 was the only staff using the sit-to-stand lift with Resident 92 and, there should have been two people assisting when using the sit-to-stand machine. The DON stated there could have been a different outcome with two people in which Resident 92 would not have been injured. The DON stated he did not know when the assessment for the sit-to-stand lift machine was done and did not know when staff started using the sit-to-stand lift machine in moving Resident 92 from bed to wheelchair. The DON stated that on Resident 92's MDS, dated [DATE], Resident 92 required two-person assistance during transfers from bed to wheelchair. The DON stated he did not know why CNA 1 did not have another staff with him when moving Resident 92 on 9/9/2022 from a sitting position in bed to standing up and transfer to Resident 92's wheelchair.
During an interview on 10/27/2022 at 2:49 p.m., and concurrent record review of CNA 1's LIFT/Hoyer (LIFT referring to sit-to-stand machine) Machine Training Acknowledgment, dated 6/23/2022, the Director of Staff Development (DSD) stated CNA 1 received training on how to use the sit-to-stand machine. The DSD stated the training for the sit-to-stand machine indicated to be accomplished by two staff present during a resident transfer. A concurrent record review of CNA 1's Employee One to One In-service Training form, dated 9/16/2022, indicated CNA 1 received an in-service on how to use the sit-to-stand machine on 9/16/2022. The DSD stated CNA 1 received an in-service on the sit-to-stand machine on 9/16/2022. A concurrent record review of CNA 1's Competency Assessment, using a Mechanical Lifting Machine, dated 9/16/2022, indicated that at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift (which included the sit-to-stand lift).
During an interview on 10/28/2022 at 8:22 a.m., and concurrent record review of the undated sit-to-stand manual, the DON, who provided the manual stated two assistants are recommended for transfer to a wheelchair. The DON stated the manual indicated one assistant stands behind the chair and the other operates the patient lift. The manual indicated the assistant behind the chair pulls back on the grab handle or sides of the sling to seat the patient well into the back of the chair. The DON stated there needs to be two staff present when operating the sit-to-stand manual. The DON stated the importance of two staff using the sit-to-stand lift for resident transfer is for safety so that a resident is not injured during transfer. The DON stated there was no facility policy for the use of the sit-to-stand machine. The DON stated Resident 92 did not have an assessment for the use of the sit-to-stand machine.
During an interview on 10/28/2022 at 9:10 a.m., CNA 1 stated he was trained to have another staff present when he transfers a resident with the sit-to-stand machine. CNA 1 stated he operated the sit-to-stand machine with no other staff assisting on 9/9/2022, when Resident 92 fell during transfer from bed to wheelchair. CNA 1 stated that when Resident 92 fainted, CNA 1 helped Resident 92 fall to the floor. CNA 1 stated Resident 92 really wanted to get up into the wheelchair that day and that was why he did not ask another staff to help him when he transferred Resident 92.
During an interview on 10/28/22 at 10:50 a.m., the DON stated there is no facility policy for the sit-to-stand lift. The DON stated the two-person assistance indicated in the sit-to-stand training conducted by the DSD is what the facility uses as a guide in place of a facility policy.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 93's admission Record indicated the facility originally admitted the resident on 3/29/2022 and readmitte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 93's admission Record indicated the facility originally admitted the resident on 3/29/2022 and readmitted on [DATE] with diagnosis including type 2 diabetes mellitus (a condition that affects the way the body regulates and uses blood sugar), chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing related problems), and end stage renal (kidneys) disease dependent on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).
A review of Resident 93's MDS, dated [DATE], indicated the resident had moderate cognitive impairment (damaged or is not working properly). The MDS indicated Resident 93 required total assistance with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing.
A review of Resident 93's Physician Orders, dated 9/26/2022, indicated Enteral (a route by way of tube to deliver nutrition to the stomach or intestines) Formula Nepro 1.8 at 50 milliliters (ml) per hour (hr) over 20 hours to provide 1000 ml/2160 kilocalories (kcal) in 24 hours. On at 7 p.m. and off at 11 a.m. Infuse feeding until total volume is infused via a pump.
A review of Resident 93's Physician Orders, dated 10/24/2022, indicated Enteral Formula Nepro 1.8 at 75 ml per hr over 16 hours to provide 1200 ml/2160 per kcal in 24 hours. On at 7 p.m. and off at 11 a.m. Infuse feeding until total volume is infused via a pump.
During an observation on 10/25/2022 at 7:59 a.m., in Resident 93's room, observed GT feeding pump off.
On 10/25/2022 at 8:33 a.m., during a concurrent observation and interview in Resident 93's room, ADON turned on the GT pump and the GT pump indicated 457 ml volume infused. The ADON stated Resident 93 was supposed to have his GT feeding still on because the resident had not met the ordered 1200 ml for the day. The ADON stated Resident 93 not getting his GT feeding according to physician's orders placed the resident at risk for weight loss, not getting his nutrients, feelings of hunger, and dehydration. The ADON further stated the resident is diabetic which placed him at risk for low blood sugar that could cause confusion or alteration in mental status, and possible hospitalization.
On 10/26/2022 at 9:16 a.m., during a concurrent interview and record review, the Director of Nursing (DON) stated Resident 93's GT feeding order was to be on at 7 p.m. and off at 11 a.m. or when the dose had been completed. The DON stated dose complete means the pump will stop running when it reached the set dose. The DON calculated Resident 93's GT feeding that was infused from 10/24/2022 at 7 p.m. to 10/25/2022 at 8 a.m., the DON stated Resident 93 should have received 975 ml; the DON stated the pump indicating 457 ml on 10/25/2022 at 8:33 a.m. was not accurate and was less than what the resident should have received at the time. The DON stated Resident 93's GT feeding being left off was not following physician's orders and placed Resident 93 at risk for weight loss and hypoglycemia (low blood sugar).
On 10/26/2022 at 11:27 a.m., during a concurrent observation and interview, in Resident 93's room, Licensed Vocational Nurse 3 (LVN 3) turned the GT feeding pump on and the pump indicated 1000 ml infused, observed LVN 3 pressed the run/stop button, and the pump began to make a beeping sound. LVN 1 stated the pump making a beeping sound meant that the dose had been completed. LVN 3 stated 1000 ml was not the correct order as Resident 93 should have received 1200 ml. LVN 3 stated the pump was probably set up incorrectly with the incorrect dose limit when the order was changed. LVN 3 stated Resident 93 not receiving his GT feeding as ordered placed him at risk for weight loss and weakness.
A review of Resident 93's Physician Orders, dated 9/26/2022, indicated admission weight followed by weekly weights for three weeks and then monthly.
A review of Resident 93's Weights and Vitals Summary from 9/7/2022 to 10/27/2022 indicated the following:
- 9/7/2022: 176 pounds (lbs.); (did not indicate the source the weight was obtained from)
- 9/19/2022: 177 lbs. (wheelchair) - Resident was transferred to the hospital on 9/18/2022.
- 10/7/2022: 159 lbs. (did not indicate the source the weight was obtained from)
- 10/18/2022: 171 lbs. (did not indicate the source the weight was obtained from)
A review of Resident 93's weight recorded on 9/7/2022 and 10/7/2022 indicated the resident lost 17 pounds in 30 days or 9.7%, a severe weight loss.
On 10/27/2022 at 10:35 a.m., during a concurrent interview and record review, the DON stated Resident 93 did not have a recorded weight upon readmission but should have had one. The DON stated not monitoring the resident's weight according to physician's orders and facility policies placed the resident at risk for inaccurate weight loss and inaccurate interventions. During a concurrent interview and record review, there was no documented evidence that nursing reported resident's weight loss on 10/7/2022 to the physician. The DON stated Resident 93's weight loss was a change of condition and should have been reported to the physician.
A review of Resident 93's Nutrition Assessment completed by the Registered Dietician (RD), dated 9/29/2022, indicated the resident's most recent weight was 177 lbs with estimated nutritional needs of 2000-2400 kcal and 96-112 grams protein. The Nutrition Assessment indicated a recommendation to change to Nepro 1.8 at 75 ml per hr over 16 hours to provide 1200 ml per kcal. There was no documented evidence that this recommendation was reported to Resident 93's physician for approval or disapproval.
A review of Resident 93's Medication Administration Record (MAR) from 9/26/2022 to 10/28/2022 indicated the resident received GT feeding as follows:
- Nepro 1.8 at 50 ml per hr over 20 hours to provide 1000 ml/2160 kcal from 9/27/2022 to 10/17/2022
- Nepro 1.8 at 50 ml per hr over 20 hours to provide 2160 ml/2160 kcal from 10/18/2022 to 10/24/2022
- Nepro 1.8 at 75 ml per hr over 16 hours to provide 2160 ml/1800 kcal starting 10/25/2022
On 10/27/2022 at 11:18 a.m., during a concurrent interview and record review, the RD stated Resident 93's admission order was Nepro 1.8 50 ml/hr over 20 hours to provide 1000 ml/1800 kcal, but on 9/29/2022 she made a new recommendation Nepro 1.8 @ 75 ml/hr over 16 hours to provide 1200ml/2160 kcal. The RD stated she sends her recommendations to nursing department, then nursing department places the order. The RD stated the team meets for weekly weight meeting to discuss weight variances. During a concurrent interview and record review, there was no weekly weight meeting for Resident 93 on the week of 10/2/2022 to 10/8/2022. The RD stated the next meeting was on 10/11/2022 where she requested for Resident 93's dry weight (weight without the excess fluid that builds up between dialysis treatments) and recommended to continue to monitor the resident's weight weekly. The RD stated Resident 93's weight is much more manageable because he is on steady feeding which meant continuous feeding daily on schedule. The RD stated if Resident 93's GT feeding was being left off or not being run completely, then the resident was not getting the recommended amount which could result in weight loss. The RD stated the potential consequence of weight loss is muscle wasting.
On 10/28/2022 at 10:55 a.m., during a concurrent interview and record review of Resident 93's weight records, Restorative Nursing Assistant 1 (RNA 1) stated RNAs are responsible for weighing the residents on a weekly or monthly basis. RNA 1 stated the facility was not weighing Resident 93 because he is on dialysis, instead the facility looked at post dialysis weight multiply by 2.2 and record the result on the RNA binder. There was no evidence recorded on the RNA binder of Resident 93's weekly weights; there were monthly weights recorded for the months of March, April, May, August, September, and October. RNA 1 stated Dietary Services Supervisor (DSS) is responsible for documenting the weights on the facility's electronic chart point click care (PCC).
A review of the facility's policy and procedure (P&P), titled, Enteral Nutrition, dated 4/2022, indicated, Adequate nutritional support through enteral nutrition is provided to residents as ordered . 11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include . f. The volume/rate goals and recommendations .
A review of the facility's P&P, titled, Weight Assessment and Intervention, dated 4/2022, indicated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents . 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. 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 Dietician in writing. Verbal notification must be confirmed in writing. 4. The Dietician will respond within 24 hours of receipt of written notification .
Based on observation, interview and record review, the facility failed the following for two of four sampled residents (Resident 5 and Resident 93):
a. For Resident 5 who had severe weight losses (weight loss greater than 5 percent [%, out of 100] for one month interval, 7.5% for three months interval, and 10% for six months interval) on 7/8/2022, 8/8/2022, 9/7/2022, and 10/13/2022, the facility:
1. Failed to ensure the Registered Dietitian's (RD's) recommendation on 6/23/2022 to add 120 milliliter (ml, unit of measurement) TwoCal (a nutritionally complete, high-calorie formula designed to meet the needs of people with increased protein and calorie requirements) twice a day during medication pass was given to Resident 5.
2. Failed to ensure the RD's recommendation on 7/21/2022 to add four ounces (oz., unit of measurement) of high protein nourishment with meals three time a day was added to Resident 5's diet.
3. Failed to ensure the RD's recommendation on 8/12/2022 for Resident 5 to receive Restorative Nursing Assistant (RNA, staff who have special training, skills and knowledge in therapeutic or rehabilitative techniques that they put into practice under the direct supervision of a licensed professional) feeding assistance during breakfast and lunch was implemented.
4. Failed to ensure the RD's recommendation on 9/28/2022 for Resident 5 to take Megace ES (an appetite stimulant) or equivalent per Medical Doctor's (MD's) discretion was carried out. This recommendation was carried out on 10/11/2022.
These deficient practices resulted to Resident 5's hospitalization on 8/16/2022 to 8/21/2022 to the General Acute Care Hospital 1 (GACH 1) with diagnosis including dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) and chronic anemia (decreased oxygen-carrying capacity of the blood leading to tissue hypoxia [absence of enough oxygen in the tissues to sustain bodily functions]). As of 10/13/2022, Resident 5 had 14.1 % severe weight loss in three months and 21% severe weight loss in six months.
b. For Resident 93, the facility failed to provide gastrostomy tube (GT - a tube inserted through the belly that brings nutrition directly to the stomach) according to physician's orders and to ensure weights were obtained and documented in Resident 93's medical record according to physician's orders and the facility's policy and procedure. These deficient practices had the potential to result in weight loss and inaccurate weight tracking for Resident 93.
Findings:
a. A review of Resident 5's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty), dementia (a group of thinking and social symptoms that interferes with daily functioning), and unspecified intellectual disabilities (a broad category of disorders characterized by an impairment to the intelligence an individual possesses).
A review of Resident 5's General Acute Hospital 1's Skilled Nursing Facility (SNF) Transfer Orders, dated 8/21/2022, indicated GACH 1 admitted Resident 5 on 8/16/2022 and discharged back to the SNF facility on 8/21/2022, with diagnosis including dehydration, chronic anemia, and dysphagia (swallowing difficulties).
A review of Resident 5's Quarterly Minimum Data Set (MDS, a standardized assessment and screening tool), dated 10/6/2022, indicated Resident 5 had the ability to sometimes makes self-understood and ability to sometimes understand others. The MDS indicated Resident 5 required extensive assistance for transfer, dressing, toilet use, personal hygiene, bathing and limited assistance with eating.
On 10/24/2022 at 12:21 p.m., during an observation, Resident 5 was sitting in a wheelchair directly in front of the overbed table with a meal tray on top. Resident 5 was observed not eating at this time. There was no staff in the room helping with feeding or supervision to Resident 5. During a concurrent interview, Resident 5 was asked about the food, Resident 5 mumbled and was incoherent.
On 10/24/2022 at 12:45 p.m., during an observation, Resident 5 was still sitting in the wheelchair in front of the overbed table with a meal tray on top. Resident 5 was observed still not eating at this time. Meal tray contained a plate with pureed food (food that has been crushed so that it forms a thick, smooth liquid) which were untouched, two bowls of soup containing yellow colored soup with one bowl half consumed, a cup of empty apple sauce and an eight oz. glass of thickened milk 1/4 consumed. There was no meal ticket on the tray.
On 10/24/2022 at 12:58 p.m., during an observation, Certified Nurse Assistant 9 (CNA 9) was removing the meal tray of Resident 5. During a concurrent interview, CNA 9, upon exiting Resident 5's room, stated Resident 5 was finished eating. A photograph of Resident 5's meal tray was taken while interviewing CNA 9.
On 10/26/2022 at 10:49 a.m., during a concurrent interview and record review of CNA 9's documentation of Resident 5's meal percentage intake on 10/24/2022, the Assistant Director of Nursing (ADON) stated CNA 9 documented Resident 5 had a 26% to 50% meal intake for lunch on 10/24/2022. During a concurrent record review of the photographs taken on 10/24/2022 of Resident 5's meal tray after CNA 9 took Resident 5's meal tray away, the ADON stated an estimate of Resident 5's intake was at 0 to 25%. The ADON stated CNA 9's documentation of 26% to 50% meal intake was inaccurate. The ADON stated an intake of 0 to 25% can result to a significant weight loss.
On 10/26/2022 at 11 a.m., a record review of Resident 5's Weights and Vitals Exceptions (dated 3/3/2022 to 10/13 2022) and Registered Dietitian's (RD's) Progress Notes (dated 6/23/2022 to 9/28/2022), together with the ADON, indicated the following:
1. Resident 5's Weights and Vitals Exceptions:
a. 3/3/2022 - 167 pounds (lbs., unit of measurement)
b. 4/16/2022 - 162 lbs.
c. 5/8/2022 - 160 lbs.
d. 6/2/2022 - 159 lbs.
e. 6/11/2022 - 156 lbs.
f. 6/25/2022 - 152 lbs.
g. 7/8/2022 - 149 lbs. (13 lbs. or 8% severe weight loss from 4/16/2022 or in three months)
h. 8/4/2022 - 144 lbs.
i. 8/8/2022 - 141 lbs. (8 lbs. or 5.4% severe weight loss from 7/8/2022 or in one month; 19 lbs. or 11.9% severe weight loss from 5/8/2022 or in three months)
j. 8/15/2022 - 141 lbs.
k. 9/7/2022 - 132 lbs. (9 lbs. or 6.4% severe weight loss from 8/8/2022 or in one month; 24 lbs. or 15.4% severe weight loss from 6/11/2022 or in three months; 35 lbs. or 21% severe weight loss from 3/3/2022 or in six months)
l. 10/13/2022 - 128 lbs. (21 lbs. or 14.1% severe weight loss from 7/8/2022 or in three months; 34 lbs. or 21% severe weight loss from 4/16/2022 or in six months)
2. Progress Notes (RD-Registered Dietitian) Forms for Resident 5:
a. A review of the RD Progress Notes, dated 6/23/2022, indicated Resident 5 had 20 lbs. weight loss in six months and weekly weights indicate six lbs. loss. The RD recommended to add 120 ml TwoCal twice a day during medication pass.
b. A review of the RD Progress Notes, dated 7/21/2022, indicated Resident 5 had significant weight changes with 10 lbs. weight loss in one month and 23 lbs. weight loss in 6 months. The RD recommended to change diet to pureed/nectar thick liquid (liquids coats and drips off a spoon like a lightly set gelatin) and add 4 ounces of high protein nourishment with meals three time a day.
c. A review of the RD Progress Notes, dated 8/12/2022, indicated the Interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients) reviewed Resident 5 due to significant weight losses of 18 lbs. in 3 months or 11.11% and 28 lbs. in 6 months or 16.2%. The RD requested RNA feeding assistance during breakfast and lunch and requested updates on food preferences.
d. A review of the RD Progress Notes, dated 9/28/2022, indicated the IDT team reviewed Resident 5 due to 12-lbs. weight loss. The RD recommended an appetite stimulant, Megace ES, or equivalent per MD discretion.
On 10/26/22 at 4:13 p.m., during a concurrent record review and interview, the RD stated she recommended 120 ml TwoCal twice a day during medication pass on 6/23/2022, four oz. of high protein nourishment with meals three times a day on 7/21/2022, RNA feeding assistance during breakfast and lunch on 8/12/2022, and appetite stimulant Megace ES or equivalent per MD discretion on 9/28/2022. The RD, during a concurrent review of the photograph of the lunch meal tray taken on 10/24/2022, stated that it should have been documented as 1 to 25 % and not 26% to 50% which was inaccurate. The RD stated had the facility staff carried out the RD recommendations, it would have resulted to a different outcome with Resident 5's weight changes.
On 10/27/22 at 9:06 a.m., during an interview, CNA 9 stated she was assigned to Resident 5 on 10/24/2022, and during lunch she passed the meal trays to Resident 5 and to other residents. CNA 9 stated she set up the tray on the overbed table of Resident 5 who was sitting in his wheelchair at that time and then she (CNA 9) left to feed another resident in another room. CNA 9 stated that Resident 5 was not on the RNA feeding program on 10/24/2022 that was why she did not assist in feeding Resident 5.
On 10/27/22 at 11:46 a.m., during a concurrent interview and record review of Resident 5's Medication Administration Record (MAR) on 6/2022 to 10/2022, physician's orders, and care plans, the ADON stated there was no documented evidence that the RD recommendation on 6/23/22 to add TwoCal 120 ml twice a day was given to Resident 5 during medication pass. The ADON stated there was no documented evidence that the RD recommendation on 7/21/2022 to add four oz. of high protein nourishment with meals three times a day was given to Resident 5. The ADON stated there was no documented evidence the RD recommendation on 8/12/2022 to place Resident 5 on the RNA feeding assistance program for breakfast and lunch was done. The ADON stated there was no documented evidence Resident 5 had an RNA feeding program care plan. The ADON stated the RD recommendation on 9/28/2022 for Resident 5 to have an appetite stimulant was only carried out on 10/11/2022. The ADON stated that if Resident 5 was losing weight and was not provided interventions, he will continue to lose weight and with his comorbidities he will decline and can suffer malnutrition which could result to dehydration and complications that could lead to hospitalization. During a concurrent record review of Resident 5's laboratory results report, dated 10/26/2022, the ADON stated Resident 5's Prealbumin (a blood test to see whether you are getting enough protein in your diet) was at 15 milligram per deciliter (mg/dL, a unit of measurement) which was flagged as LOW with a normal reference range of 18 to 38 mg/dL. The ADON stated a low prealbumin means Resident 5 needs more protein in his diet or more protein supplement and the low number would indicate malnutrition and dehydration that can be caused by poor meal intake. The ADON stated that if a resident is consuming a meal below 50%, it can result to malnutrition.
A review of the facility's current policy and procedure titled, Weight Assessment and Intervention, last reviewed on 4/2022, indicated that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss 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 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.
Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the:
a.
Resident's target weight range (including rationale if different from ideal body weight);
b.
Approximate calorie, protein, and other nutrient needs compared with the resident's intake;
c.
The relationship between current medical condition or clinical situation and recent fluctuations in weight; and
d.
Whether and to what extent weight stabilization or improvement can be anticipated.
The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example:
a.
Cognitive or functional decline;
b.
Chewing or swallowing abnormalities;
c.
Pain;
d.
Medication-related adverse consequences;
e.
Environmental factors (such as noise or distractions related to ding);
f.
Increased need for calories and/or protein;
g.
Poor digestion or absorption;
h.
Fluid and nutrient loss; and or
i.
Inadequate availability of food or fluids.
Care Planning:
1.
Care Planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident`s legal surrogate.
2.
Individualized care plans shall address, to the extent possible:
a.
The identified cause of weight loss;
b.
Goals and benchmarks for improvement;
c.
Time frame and parameters for monitoring and reassessment.
Interventions:
1.
Interventions for undesirable weight loss shall be based on careful consideration of the following:
a.
Resident choice and preferences;
b.
Nutrition and Hydration needs of the resident;
c.
Functional factors that may inhibit independent eating;
d.
Environmental factors that may inhibit appetite or desire to participate in meals;
e.
Chewing and swallowing abnormalities and the need for diet modifications;
f.
Medications that may interfere with appetite, chewing, swallowing, or digestion;
g.
The use of supplementation and/or feeding tubes; and
h.
End of life decisions and advance directives.
2.
The Dietitian will discuss undesired weight gain with the resident and/or family.
3.
Interventions for undesired weight gain should consider resident preferences and rights. A weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement.
4.
If a resident declines to participate in a weight loss goal, the Dietitian will document the resident`s wishes, and those wishes will be respected.
A review of the facility's current policy and procedure titled, Restorative Nursing Services, last reviewed on 4/2022, indicated that residents will receive restorative nursing care as needed to help promote optimal safety and independence restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care.
A review of the facility's current policy and procedure titled, Assisting the Resident with In-room Meals, last reviewed on 4/2022, indicated that the purpose of this procedure is to provide appropriate assistance for resident who chose to receive meals in their rooms Review the resident's care plan and provide for any special needs of the resident.
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** c. A review of Resident 77's Face Sheet indicated the facility admitted the resident on [DATE], with diagnoses that included dem...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 77's Face Sheet indicated the facility admitted the resident on [DATE], with diagnoses that included dementia (decline in mental ability severe enough to interfere with daily functioning/life), abdominal aortic aneurysm (a bulge or swelling in the aorta, the main blood vessel that runs from the heart down through the chest and abdomen), and malignant neoplasm of lung (a cancer that begins in the lungs).
A review of Resident 77's MDS, dated [DATE], indicated the resident was cognitively intact. The MDS indicated the resident needed one-to-two-person assistance with bed mobility, transfer, walking in corridor, locomotion, dressing, eating, toilet use and personal hygiene.
A review of Resident 77's undated POLST was not signed by the resident. The advance directive was not found in Resident 77's clinical record.
On [DATE] at 9:11 a.m., DON stated he could not find an advanced directive in Resident 77's chart. DON further stated we need to make one. DON stated Advance Directives were offered to all residents to help others know what kind care the resident wanted. The resident could either make one or refuse to formulate an advance directive.
A review of the facility's policy and procedure titled Advance Directives last revised on 4/2022 indicated upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 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. Information about whether the resident has executed an advance directive shall be displayed prominently in the medical record.
b. A review of Resident 66's Face Sheet indicated the resident was readmitted to facility on [DATE], with diagnoses that included epilepsy (a central nervous system [neurological] disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness.), type 2 diabetes mellitus with other circulatory complications (chronic condition that affects the way the body processes blood sugar [glucose]), and muscle wasting and atrophy (decrease in size of an organ or tissue; wasting).
A review of the MDS, dated [DATE], indicated Resident 66 had the ability to make self-understood and understand others sometimes. The MDS indicated Resident 66 required extensive assistance with eating and total dependence with bed mobility transfer and toilet use.
A review of facility document titled Care Plan Conference Summary, dated [DATE], indicated Resident 66's Family Member attended conference and reviewed Physician Orders for Life Sustaining Treatment (POLST) (form is a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness.) with preference of cardiopulmonary resuscitation (CPR) (an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) and full treatment, artificial nutrition including feeding tubes with no changes/updates at this time.
A review of Resident 66's Order Summary Report, dated [DATE], indicated the resident's full treatment primary goal was to prolong life by all medically effective means. The record indicated resident's treatment described in selective treatment and comfort focused treatment, use intubation, advanced airway intervention, mechanical ventilation and cardioversion as indicated.
During a concurrent observation and interview, on [DATE] at 10:38 a.m., Resident 66 chart with document titled Your Right to Make Medical Decisions About Your Medical Treatment, dated [DATE], indicated Resident 66 had an advanced directive, no advanced directive noted in chart. During a review of chart with Licensed Vocational Nurse (LVN 4), LVN 4 verified he did not see an advanced directive in the chart.
During a concurrent observation and interview, on [DATE] at 10:45 a.m., the Social Services Assistant (SSA) stated she could not find advanced directive in chart. SSA stated she was new in facility and had not been able to review the charts in Station 3, would look to see if they are stored some where else.
A review of facility's Progress Notes, dated [DATE] at 2:25 p.m., indicated Resident 66's son called and stated that Resident 66 did not have an advanced directive, nor had executed on and the only one he had signed regarding medical decision was her POLST. Residents 66's Family Member was made aware he needed to review and update advanced directive acknowledgement as it currently states that resident has executed and advanced directive.
During an interview on [DATE] at 8:23 a.m., SSA stated she was able to get a hold of Resident 66's Family Member and he stated that Resident 66 did not have an advanced directive and had filled out the POLST. SSA stated documentation was inaccurately documented. SSA stated that not accurately documentation the advanced directives could be a discrepancy on Resident 66 care and needs.
During an interview, on [DATE] at 11:06 a.m., the Director of Nursing (DON) stated that if advanced directives were inaccurately documented, it could have the wrong information and possibly given the wrong care for end-of-life for the resident. The DON stated it would not be respecting the residents' rights to their own care.
Based on observation, interview, and record review, the facility failed to ensure Social Services (SS) informed residents and their responsible party about their right to formulate an advance directive (a written statement of a person's wishes regarding medical treatment) upon admission for three out of five sample residents (Resident 17, Resident 66, and Resident 77) investigated for advance directives.
This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding their health care.
Findings:
a. A review of Resident 17's Face Sheet indicated the facility originally admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses that included sepsis (the body's overwhelming and life-threatening response to an infection that can lead to tissue damage, organ failure, and death), metabolic encephalopathy (a syndrome of temporary or permanent disturbance of brain functions), dysphagia (difficulty swallowing), acute kidney failure (when the kidneys stop working suddenly), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
A review of Resident 17's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE], indicated the resident had severely impaired cognitive (thought process) skills for daily decision making. The MDS indicated the resident was totally dependent on staff for eating and personal hygiene, and required extensive assistance for bed mobility, transfers, dressing, and toilet use.
On [DATE] at 9:06 a.m., during an interview, the Social Services Director (SSD) stated she had spoken to Resident 17's responsible party yesterday and determined that the resident did not have an advance directive (a written statement of a person's wishes regarding medical treatment). The SSD also stated they did not have a copy of the resident's power of attorney paperwork in the resident's medical record. The SSD stated she could not find any documentation indicating that the resident's responsible party was informed of her right to formulate an advance directive upon admission. The SSD stated that the nurses were supposed to review advance directives with the resident and his/her responsible party upon admission. The SSD stated it was important for residents to have an advance directive, so the facility was aware of the wishes and desires of the family.
On [DATE] at 9:14 a.m., during a concurrent interview and record review, Registered Nurse 2 (RN 2) stated there was no advance directive Acknowledgement Form in the resident's medical record indicating that the right to formulate an advance directive had been discussed with the resident and her responsible party. RN 2 also stated she did not find any documentation in the nurses' notes indicating they had communicated with the resident's responsible party regarding formulating an advance directive.
On [DATE] at 11:54 a.m., during an interview, the Director of Nursing (DON) stated it was the Social Services department that was responsible for communicating with residents and their responsible party regarding their right to formulate an advance directive. The DON stated it was important to discuss advance directives so the facility could know what the resident's desire was when it came to end-of-life decisions.
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 records for one two of nineteen sampled residents (Resident 102) when the Medication ...
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Based on observation, interview, and record review, the facility failed to ensure protection of resident's medical records for one two of nineteen sampled residents (Resident 102) when the Medication Administration Record (MAR) was left open and unattended by staff for Resident 102.
This deficient practice had the potential to violate Resident 102's right to privacy and confidentiality.
Findings:
A review of admission Record indicated the facility readmitted Resident 102 on 1/17/2020 with diagnoses including hemiplegia (condition, caused by a brain injury, that results in a varying degree of weakness, stiffness [spasticity] and lack of control in one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominate side, essential (primary) hypertension (a condition in which the blood vessels have persistently raised pressure), and peripheral vascular disease (slow and progressive circulation disorder).
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/25/2022, indicated Resident 102 had the ability to make self-understood and understand others.
During a concurrent observation and interview on 10/24/2022 at 9:23 a.m., observed medication cart outside of a resident's room with no staff present while the computer screen was opened to Resident 102's MAR. Observed Licensed Vocational Nurse (LVN 4) walking back to the medication cart. LVN 4 stated that he usually locks the computer screen. LVN 4 stated the computer screen must be locked for resident's privacy; if it was left unlocked, people or residents can access the resident's information who would not otherwise have access to it.
During an interview on 10/27/2022 at 11:00 a.m., with the Director of Nursing (DON), the DON stated screens being left open with residents' information with no staff present is an issue with Health Insurance Portability and Accountability Act (HIPAA - a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) and privacy for residents.
A review of the policy and procedure titled Resident Rights, revised 4/2022, indicated that federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to (t.) privacy and confidentiality. Policy further indicated unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues.
A review of the facility's policy and procedure titled Confidentiality of Information and Personal Privacy, last revised on 4/2022 indicated facility will protect and safeguard resident confidentiality and personal privacy. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Access to resident personal and medical records will be limited to authorized staff and business associates.
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`s Interdisciplinary Team (a group of experts from various disciplines workin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility`s Interdisciplinary Team (a group of experts from various disciplines working together to treat your ailment, injury, or chronic health condition) failed to review and revise the comprehensive care plans to include measurable objectives and timetables to meet the resident`s physical, psychosocial and functional needs for one of two sampled resident (Resident 78) investigated under the care area care planning.
This deficient practice had the potential for the residents to not receive appropriate care and treatment specific to the residents' needs.
Findings:
A review of Resident 78`s Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hyperlipidemia (an abnormally high concentration of fats in the blood), acute pulmonary edema (a condition caused by too much fluid in the lungs), and morbid obesity (a disorder involving excessive body fat that increases the risk of health problems).
A review of Resident 78's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 9/15/2022, indicated Resident 78's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making was intact. The MDS indicated that Resident 78 required extensive assistance with transfer, dressing, toilet use, and for personal hygiene.
During a concurrent interview and record review, on 10/27/22 at 9:58 a.m., Assistant Director of Nursing (ADON) stated IDT meeting were done quarterly and as needed. ADON stated if the resident was alert, they would be invited otherwise the responsible party would be invited instead.
During a concurrent interview and record review, on 10/27/22 at 10:11 a.m., Registered Nurse 2 (RN2) stated IDT were spearheaded by Social Services staff and responsible parties were informed and invited to participate in the meeting. RN 2 stated the initial meeting was done upon admission, then quarterly or as needed. RN2 stated that the facility discussed the treatment plans, medications that resident`s physician`s have ordered, physical, psychosocial and functional needs of the resident that would be incorporated in the comprehensive care plan. RN2 stated the last IDT meeting was done on 3/10/2022 and should have one done on 6/10/2022 and 9/10/2022 for the quarterly IDT meeting. RN2 stated the department involved in the care of the resident included Nursing Department, Dietary Department, Activities Department, Social Services, and the Rehabilitation Department. RN 2 stated the facility should have met quarterly to update the care needs of the resident. RN2 stated if the meetings were not done then they would not know the resident`s concerns and care needs. RN2 stated the residents would have a chance in these meetings to have a say on their treatment plan and to be given an opportunity to either agree or disagree on the treatment plan.
A review of the facility`s policy and procedure dated 4/2022, titled Care Planning-Interdisciplinary Team, indicated that the facility`s Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The resident, the resident`s family and/or the resident`s legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident`s care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming were provided care and services to maintain good personal hygien...
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Based on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming were provided care and services to maintain good personal hygiene for one of one sampled resident (Resident 91) investigated under the care area activities of daily living (ADL- activities related to personal care).
This deficient practice has the potential to result in a negative impact on the resident`s self- esteem due to an unkempt appearance.
Findings:
A review of Resident 91`s Face Sheet indicated the facility admitted the resident on 9/07/2022 with diagnoses that included chronic muscle weakness, gastro-esophageal reflux disease (digestive disease in which stomach acid or bile irritates the food pipe lining) and dementia (a group of thinking and social symptoms that interferes with daily functioning).
A review of Resident 91's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 9/23/2022, indicated Resident 40's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired. The MDS indicated Resident 40 required extensive assistance for eating, transfer, dressing, toilet use, and for personal hygiene.
During a concurrent observation and interview, on 10/27/22, accompanied by Assistant Director of Nursing (ADON), Resident 91 was lying in bed, awake, alert and verbally responsive. Resident 91's` hand was observed to have long and untrimmed fingernails. ADON stated ADL care included bathing, feeding, showering and trimming of the residents` fingernails. ADON stated if residents` fingernails were observed to be long, it should be trimmed for reasons including preventing injury when residents` scratch themselves.
A review of Resident 91`s Nursing Care Plan (NCP- is a formal process that correctly identifies existing needs and recognizes potential needs or risks) on ADL`s, indicated a problem of ADL self-care performance deficit related to disease process indicated an intervention that included personal hygiene/oral care with assistance to be provided by staff.
A review of the facility`s policy and procedure dated April 2022, titled Fingernails/Toenails, Care of, indicated that the purpose of this policy and procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that Restorative Nursing Assistants (RNA - responsible for following a resident care plan in helping residents with range of motion ...
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Based on interview and record review, the facility failed to ensure that Restorative Nursing Assistants (RNA - responsible for following a resident care plan in helping residents with range of motion [the capability of a joint to go through its complete spectrum of movements]) and licensed nurses reported to the rehabilitation department that a resident was refusing her RNA exercises for one (Resident 47) out of three sampled residents investigated for position and mobility.
This deficient practice had the potential to decrease Resident 47's range of motion and mobility which could affect the resident's overall function.
Findings:
A review of Resident 47's admission Record indicated the facility originally admitted the resident on 11/11/2021 and readmitted the resident on 12/18/2021 with diagnoses that included radiculopathy in the lumbar region (an inflammation of a nerve root in the lower back), morbid obesity (a complex chronic condition in which a person has a body mass index [measure of body fat based on height and weight] of 40 or higher), difficulty in walking, and muscle wasting and atrophy (loss of muscle tissue).
A review of Resident 47's Minimum Data Set (MDS - a standardized assessment and care screening tools), dated 8/19/2022, indicated the resident had intact cognition (thought process) and required extensive assistance from staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene.
On 10/26/2022 at 11:07 a.m., during a concurrent interview and record review, Registered Nurse 2 (RN 2) stated that according to the 10/2022 Restorative Nursing Assistant Treatment Record (document containing the resident's participation with the prescribed RNA program), Resident 47 had been refusing her RNA exercises.
On 10/26/2022 at 11:15 a.m., during an interview, RN 2 stated that, according to the Director of Rehabilitation (DOR), he was not aware that the resident had been refusing her RNA exercises. RN 2 stated that meant that the nurses were not communicating her refusals to him.
On 10/27/2022 at 8:33 a.m., during a concurrent interview and record review, Registered Nurse 3 (RN 3) stated that Resident 47 had a physician's order, ordered on 3/2/2022, for active assisted range of motion (AAROM - resident uses the muscles around a weak joint to complete stretching exercises with the help of a physical therapist or restorative nursing assistant) exercises for bilateral (both sides) lower extremities every day, five times a week, as tolerated.
On 10/27/2022 at 8:36 a.m., during an interview, Restorative Nursing Assistant 2 (RNA 2) stated she was the assigned RNA for Resident 47 that day and worked with her twice previously. RNA 2 stated she had never actually done RNA exercises with the resident because the resident usually refused. RNA 2 stated she documented the resident's refusal and reported it to Licensed Vocational Nurse 4 (LVN 4).
On 10/27/2022 at 8:40 a.m., during an interview, LVN 4 confirmed that the RNAs report to him when Resident 47 refuses her RNA exercises. LVN 4 stated he will offer the exercises to the resident multiple times, but if the resident still refused, then he would document her refusal. LVN 4 stated if it was an ongoing issue, he would notify Social Services and the rehabilitation department.
On 10/27/2022 at 8:47 a.m., during a concurrent interview and record review, RN 2 stated she could not find any documentation that the nurses had communicated to the rehabilitation department the resident's refusal of RNA exercises.
On 10/27/2022 at 9:27 a.m., during a concurrent interview and record review, RN 2 verified the review of Resident 47's RNA Treatment Record for 10/2022 which indicated that the resident had refused her RNA exercises on the following dates:
1. 10/7/2022
2. 10/12/2022
3. 10/18/2022
4. 10/19/2022
5. 10/21/2022
6. 10/25/2022
RN 2 also verified the review of Resident 47's RNA Treatment Record for 9/2022 which indicated that the resident had refused her RNA exercises on the following dates:
1. 9/8/2022
2. 9/14/2022
3. 9/30/2022
RN 2 verified the review of Resident 47's RNA Treatment Record for 8/2022 which indicated that the resident had refused her RNA exercises on the following dates:
1. 8/18/2022
2. 8/24/2022
3. 8/30/2022
RN 2 also verified the review of Resident 47's Treatment Record for 7/2022 which indicated that the resident had refused her RNA exercises on the following dates:
1. 7/5/2022
2. 7/12/2022
3. 7/13/2022
4. 7/14/2022
5. 7/26/2022
6. 7/27/2022
On 10/27/2022 at 11:54 a.m., during an interview, the Director of Nursing (DON) stated if the resident was refusing her RNA exercises, then the RNA should notify the charge nurse and offer the exercises multiple times. The DON stated the nurses should also notify him as well as the rehabilitation department, so that the rehabilitation department can reassess the resident.
A review of the facility's policy and procedures titled, Restorative Nursing Services, last revised on 4/2022, indicated that residents will receive restorative nursing care as needed to help promote optimal safety and independence.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
b. A review of Resident 47's admission Record indicated the facility originally admitted the resident on 11/11/2021 and readmitted the resident on 12/18/2021 with diagnoses that included radiculopathy...
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b. A review of Resident 47's admission Record indicated the facility originally admitted the resident on 11/11/2021 and readmitted the resident on 12/18/2021 with diagnoses that included radiculopathy in the lumbar region (an inflammation of a nerve root in the lower back), morbid obesity (a complex chronic condition in which a person has a body mass index [measure of body fat based on height and weight] of 40 or higher), difficulty in walking, and muscle wasting and atrophy (loss of muscle tissue).
A review of Resident 47's Minimum Data Set (MDS - a standardized assessment and care screening tools), dated 8/19/2022, indicated the resident had intact cognition (thought process) and required extensive assistance from staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene.
On 10/26/2022 at 9:57 a.m., during an observation, observed Certified Nursing Assistant 6 (CNA 6) and CNA 7 providing perineal (area between the tops of the thighs) care to Resident 47 in bed. Observed CNA 6 pump soap from the soap dispenser inside the resident bathroom into wash basin and mix with water. Observed CNA 7 wash Resident 47's groin area with the soap and water. Observed CNA 7 dry the resident's perineal area without rinsing off the soap with clean water.
On 10/26/2022 at 10:30 a.m., during a concurrent interview and record review, Registered Nurse 2 (RN 2) stated that, according to Resident 47's care plan for activities of daily living (ADL - activities related to personal care) - bladder incontinence (loss of bowel and/or bladder control), one of the interventions indicated to wash and rinse the groin area.
On 10/26/2022 at 10:47 a.m., during an interview, CNA 7 confirmed that she did not wash the resident's groin area with clean water. CNA 7 stated she was supposed to rinse the resident with clean water after using soap.
On 10/26/2022 at 12:31 p.m., during a concurrent observation and interview, Housekeeping stated he used T-Chem Antibacterial Soap for the soap dispensers in the resident bathrooms. A review of the directions on the back of the T-Chem box indicate to rinse well and dry completely.
On 10/27/2022 at 11:38 a.m., during an interview, the Director of Staff Development (DSD) stated she provided in-services (training intended for those actively engaged in a profession or activity) to CNAs regarding proper perineal care. The DSD stated she teaches the CNAs that they should have two wash basins, one for dirty water, and one for clean water. The DSD stated the purpose of rinsing with clean water afterwards was to prevent infection.
On 10/27/2022 at 11:54 a.m., during an interview, the Director of Nursing (DON) stated that, during perineal care, after washing the resident's body with soap, CNAs should rinse off the resident's skin. The DON stated it was important to rinse off the soap because soap can cause dryness to the skin, which can then cause skin breakdown. The DON stated the soap can also cause itchiness and discomfort for the resident.
A review of the facility's policy and procedures titled, Perineal Care, last revised in 4/2022, indicated that the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in the same direction, using fresh water and a clean washcloth.
Based on interview and record review, the facility failed to:
a. Ensure Resident 5 who has a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine due to obstruction of normal urinary flow) was provided catheter care consistently on multiple days per physician`s order for one of two sampled residents (Resident 5) investigated under the care area of urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag).
This deficient practice had the potential to result to urinary tract infection (an infection in any part of the urinary system [the kidneys, bladder, or urethra]) which could lead to hospitalization for Resident 5.
b. Ensure Certified Nursing Assistant 6 (CNA 6) and CNA 7 provided good perineal (area between the tops of the thighs) care to a resident who is incontinent (loss of bowel and/or bladder control) by failing to rinse off the soap from the resident's skin for one (Resident 47) out of two sample residents investigated for bowel and bladder incontinence.
This deficient practice had the potential to cause increased risk of skin breakdown and urinary tract infection (UTI - an infection in any part of the urinary system) for Resident 47.
Findings:
a. A review of Resident 5`s admission Record indicated the facility admitted the resident 10/02/2019 and readmitted the resident on 08/21/2022 with diagnoses that included benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty), dementia (a group of thinking and social symptoms that interferes with daily functioning), personal history of malignant neoplasm of epididymis (uncontrolled growth of abnormal cells in the tube that stores sperm), and unspecified intellectual disabilities (a broad category of disorders characterized by an impairment to the intelligence an individual possesses).
A review of Resident 5's Quarterly Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/06/2022, indicated that Resident 5 had the ability to sometimes make self-understood and the ability to sometimes understand others. The MDS also indicated that Resident 5 required extensive assistance for transfer, dressing, toilet use, personal hygiene, bathing, and limited assistance with eating.
A review of Resident 5`s physician`s order included an order for catheter care every shift dated 4/18/2022 and reordered on 8/21/2022.
On 10/27/22 at 9:25 a.m., during an interview and record review, Assistant Director of Nursing (ADON) identified in the Treatment Administration Record (TAR) the multiple days wherein catheter care were not provided as evidenced by blank sections of the TAR. The TAR reviewed for the months of 07/2022, 9/2022, and 10/2022 indicated that no treatment were provided on the following dates:
1. 7/6/2022 during 7 a.m. to 3 p.m. shift
2. 7/6, 7/7, 7/11, 7/13, and 7/17/2022 during 3 p.m. to 11 p.m. shifts
3. 7/19 and 7/29/2022 during 11 p.m. to 7 a.m. shifts
4. 10/8, 10/14, and 10/15/2022 during 3 p.m. to 11 p.m. shifts
5. 10/8, 10/12, 10/13, 10/15, 10/16, 10/23, and 10/24/2022 during 11 p.m. to 7 a.m. shifts
According to the ADON, if catheter care is not provided consistently, it could result to accumulation of sediments and clogging which could lead to infection and hospitalization.
On 10/27/2022 at 9:28 a.m., during an interview, Treatment Nurse 1 (TRN 1) stated that catheter care included checking for any dislodgement, clogging, or leaking; cleansing the site; checking for sediments in the urine; and changing the bag as needed. Per TRN 1 all these tasks were documented in the TAR. According to TRN 1, if there is no documentation of the treatment, that means there was no treatment provided. TRN 1 added that there is always a potential for infection that's why catheter care had to be provided to prevent such.
A review of the facility`s policy and procedure, titled Suprapubic Catheter Care, last reviewed in 4/2022, indicated that the purpose of this procedure is to prevent skin irritation around the stoma (artificial opening) site and to prevent infection of the resident`s urinary tract.
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 observation, interview, and record review, the facility failed to ensure that medications for one of one sampled resident (Resident 83) were administered by a licensed nurse according to Resi...
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Based on observation, interview, and record review, the facility failed to ensure that medications for one of one sampled resident (Resident 83) were administered by a licensed nurse according to Resident 83's individual needs and the facility's policy & procedure (P&P).
This deficient practice had placed the resident at risk for seizures (sudden, temporary, bursts of electrical activity in the brain that change or disrupt the way messages are sent between brain cells) from potential missed doses.
Findings:
A review of Resident 83's admission Record indicated the facility originally admitted the resident on 11/27/2018 and readmitted the resident on 1/26/2020 with diagnosis including but not limited to epilepsy (having multiple, unpredictable seizures).
A review of Resident 83's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/16/2022 indicated the resident had the ability to make self understood and understand others. The MDS indicated Resident 83 required supervision with bed mobility, transfer, toilet use, and personal hygiene; required extensive assistance with dressing and required limited assistance with bathing.
A review of Resident 83's Self-Administration of Medication evaluation, dated 10/24/2022, indicated the resident was not safe for self-administration of medications and licensed staff to continue to administer the resident's medications.
A review of Resident 83's 10/2022 Medication Administration Record (MAR) indicated the following medications were scheduled and administered between 9 a.m. to 10 a.m.:
- Lasix (a type of medication that prevents your body from absorbing too much salt) 20 milligrams (mg-unit of measure) by mouth once a day
- buspirone (a type of medication used to treat anxiety disorders) 5 mg by mouth twice a day
- cholecalciferol (a dietary supplement used to treat vitamin D deficiency) 1000 unit (unit of measure) by mouth twice a day
- docusate sodium (a type of medication used to treat constipation) 100 mg by mouth twice a day
- levetiracetam (a type of medication used to treat epilepsy) 250 mg by mouth twice a day
- neurontin (a type of medication used to treat epilepsy and nerve pain) 100 mg by mouth twice a day
- oxybutynin (a type of medication used to treat overactive bladder [an organ that stores urine]) 5 mg by mouth three times a day
During an observation on 10/24/2022 at 9:39 a.m., in Resident 83's room, observed seven medications on the resident's bedside table while resident was sleeping.
During a concurrent observation and interview on 10/24/2022 at 9:44 a.m., in Resident 83's room, observed with the Director of Nursing (DON) seven medications on the resident's bedside table while resident was sleeping. The DON stated the facility did not have any residents on self-administration of medications. The DON stated leaving medications by a licensed nurse at the resident's bedside was not a normal procedure. The DON stated leaving medications at bedside placed the resident at risk for not taking his medications and depending on the type of medications, if for example, the resident was taking a blood pressure medication and if not taken, this could result in high blood pressure.
A review of the facility's P&P, dated, 4/2022, titled, Self-Administration of Medications, indicated, 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 . 3. If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure licensed nurses monitored the target behavior for a resident on Seroquel (antipsychotic medication used to treat certain mental/mood...
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Based on interview and record review, the facility failed to ensure licensed nurses monitored the target behavior for a resident on Seroquel (antipsychotic medication used to treat certain mental/mood conditions) for one (Resident 92) out of five sample residents investigated for unnecessary medications.
This deficient practice had the potential to result in use of unnecessary psychotropic (any drug that affects behavior, mood, thoughts, or perception) medication for Resident 92, which can lead to side effects and adverse consequence (any unexpected or dangerous reaction to a drug) such as a decline in quality of life and functional capacity.
Findings:
A review of Resident 92's admission Record indicated the facility originally admitted the resident on 8/5/2020 and readmitted the resident on 9/20/2022 with diagnoses that included schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood) and bipolar disorder (a mental health condition that causes extreme mood swings).
A review of Resident 92's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/24/2022, indicated the resident had intact cognition (thought process). The MDS indicated the resident was totally dependent on staff for dressing, toilet use, and personal hygiene, and required extensive assistance with bed mobility and transfers.
On 10/27/2022 at 2:52 p.m., during a concurrent interview and record review, Registered Nurse 2 (RN 2) stated Resident 92 had a physician's order, started on 9/25/2022, for Seroquel (antipsychotic medication used to treat certain mental/mood conditions) 25 milligrams (mg - unit of measurement) by mouth two times a day for psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) manifested by hoarding food with excessive eating.
A review of the October 2022 Medication Administration Record (MAR - used to document medications taken by residents) indicated licensed nurses were not monitoring the resident's targeted behavior.
A review of Resident 92's care plan (contains information about a patient's diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan), initiated on 8/6/2020, indicated the resident uses the psychotropic medication Seroquel 25 mg for psychosis manifested by hoarding food with excessive eating. One goal indicated that the resident will be/remain free of psychotropic drug related complications. Another goal indicated that the resident will reduce the use of psychotropic medication through the review date. Among some of the interventions listed was to monitor the behavior episodes of psychosis manifested by hoarding of food with excessive eating and tally with hashmarks for each episode on the MAR every shift.
On 10/28/2022 at 10:59 a.m., during an interview, the Director of Nursing (DON) stated for residents on antipsychotic medications, licensed nurses should be monitoring side effects and behaviors. The DON stated the purpose of monitoring the behavior was to see if the medication was effective.
A review of the facility's policy and procedures titled, Antipsychotic Medication Use, last reviewed on 4/2022, indicated that staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 102) was free from significant medication error by omitting to take the pulse bef...
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Based on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 102) was free from significant medication error by omitting to take the pulse before administering a beta blocker (medication that reduces blood pressure).
This deficient practice placed the resident at risk for an adverse reaction (any unexpected or dangerous reaction to a drug) including bradycardia (slow heart rate), fatigue, dizziness, and poor circulation.
Findings:
A review of admission Record indicated the facility readmitted Resident 102 on 1/17/2020 with diagnoses including hemiplegia (condition, caused by a brain injury, that results in a varying degree of weakness, stiffness [spasticity] and lack of control in one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, essential (primary) hypertension (a condition in which the blood vessels have persistently raised pressure), and peripheral vascular disease (slow and progressive circulation disorder).
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/25/2022, indicated Resident 102 had the ability to make self-understood and understand others.
A review of Resident 102's Order Summary Report indicated metoprolol tartrate tablet 25 milligrams (mg-a unit of measurement) give 0.5 tablet orally four times a day for hypertension, administer with meals and snack, hold (do not administer) if systolic blood pressure ([SBP] the maximum pressure the heart exerts while beating) lower than 110 or heart rate (pulse - the number of times the heart beats within a certain time period, usually a minute) lower than 60.
During a concurrent observation and interview on 10/26/2022 at 8:34 a.m., with Licensed Vocational Nurse (LVN 4), observed LVN 4 check Resident 102's blood pressure with a result of 112/67 millimeters of mercury (mmHg-unit of measure); did not observe LVN 4 check the resident's pulse. At 8:43 a.m. observed LVN 4 at Resident 102's bedside with metoprolol tartrate. Before administering the medication, asked LVN 4 if he had taken Resident 102's pulse. LVN 4 stated he has not checked the resident's pulse and he forgot. LVN 4 stated that he should have taken the resident's pulse before administering the blood pressure medication because it could cause the pulse to decrease and resident not to feel well if his pulse was low. LVN 4 stated it is ordered to check the blood pressure and pulse before administering the medication and to hold the medication if SBP is lower than 110 and or if pulse is lower than 60.
During an interview on 10/27/2022 at 10:57 a.m., with the Director of Nursing (DON), the DON stated that Resident 102's pulse not being checked before the administration of metoprolol tartrate could affect the resident's vital signs negatively, lowering the pulse or blood pressure.
A review of facility's policy and procedure titled Administering Medications, revised on 4/2022, indicated medications are administered in accordance with prescriber orders, including any required time frame. The facility checks and verifies for each resident prior to administering medications including vital signs, if necessary.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 25's admission Record indicated the facility admitted the resident on 4/28/2022 with diagnoses that incl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 25's admission Record indicated the facility admitted the resident on 4/28/2022 with diagnoses that included chronic obstructed pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dependence on supplemental oxygen (air you breathe that contains life-saving gas), and personal history of coronavirus disease 2019 (COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms).
A review of Resident 25's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/16/2022 indicated the resident had the ability to make self understood and understand others.
A review of Resident 25's October 2022 Order Summary Report indicated the following:
- oxygen at two liters (unit of measure) per minute via nasal cannula (a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) for shortness of breath (SOB)
- ipratropium-albuterol (is a combination medication used to treat COPD) 0.5-2.5 milligrams per 3 milliliters (mg/ml-unit of measure) inhale orally via nebulizer every six hours as needed for SOB
A review of Resident 25's Care Plan dated 4/30/2022, indicated the resident has COPD related to smoking and complex medical condition with a goal that the resident will be free of respiratory (lung) infections.
During an observation on 10/24/2022 at 9:51 a.m., in Resident 25's room, observed an unlabeled and undated nebulizer mask hanging over a portable oxygen cart.
During a concurrent observation and interview on 10/24/2022 at 12:48 p.m., in Resident 25's room, observed nebulizer mask in a bag on the floor. During a concurrent interview, the Assistant Director of Nursing (ADON) stated this was not the right practice. The ADON stated nebulizer mask in a bag or not should not be on the floor as this could cause infection to the resident.
During an interview on 10/27/2022 at 1:04 p.m., the Infection Preventionist Nurse (IP) stated the infection control procedure for respiratory care such as oxygen tubing and nebulizer mask is to place them in a bag, labeled, dated, and placed on the resident's table or inside a drawer and not on the floor. The IP stated a tubing or a nebulizer mask that was on the floor was considered contaminated and contaminated tubing or mask could be a source of organism that could cause infection.
A review of the facility's policy and procedure (P&P), dated, 4/2022, titled, Departmental (Respiratory Therapy) - Prevention of Infection, indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . Infection Control Considerations Related to Medications Nebulizers . 7. Store the circuit in plastic bad, marked with date and resident's name, between uses .
Based on observation, interview, and record review, the facility failed to:
1. Observe infection control measures when personal items were found in two out of four medication storage rooms (Medication Storage rooms [ROOM NUMBERS]).
This deficient practice had the potential to result in contamination of the resident's residents' medications through cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another with harmful effect).
2. Follow infection control measures when storing one of one sampled resident's (Resident 25) nebulizer mask (an equipment that covers the mouth and nose held in place by an elastic band that is used to deliver medications when connected to a nebulizer [a machine that turns liquid medication into a fine mist]).
This deficient practice placed Resident 25 at increased risk for infection.
Cross reference to F761
Findings:
a.1. During a concurrent observation and interview on 10/25/2022 at 1:30 p.m., of Medication Storage 3, observed a case of eyeglasses with eyeglasses in them with no name noted; there was no identifier for who the item belonged to. Licensed Vocational Nurse (LVN 4) stated the pair of eyeglasses should not be in medication room (storage) but should be given to social services department. LVN 4 stated that keeping personal items in the medication storage room can be a risk for infection.
During a concurrent observation and interview on 10/25/2022 at 2:01 p.m., with the Assistant Director of Nursing (ADON), the ADON stated glasses (eyeglasses) do not belong in medication room but should go to social services department; personal belongings do not belong in medication room. The ADON stated it is a risk for infection.
a.2. During a concurrent observation and interview on 10/26/2022 at 10:57 a.m., of the Medication Storage 4, observed a grocery bag with an electrical shaver with no name on who it belonged. Also observed a grey bin with a glucometer and a life alert vest. LVN 5 stated she does not know why those items were in medication room, but they should have been placed in the social services department.
During a concurrent observation and interview on 10/26/2022 at 11:38 a.m., the ADON stated that personal items in medication room should be given to social services department and should not be stored in the medication room. The ADON stated that items in medication room can be an infection control issue.
During an interview on 10/27/2022 at 11:22 a.m., the DON stated no personal items should be in the medication room. The DON stated personal items could be a source of cross contamination.
During an interview on 10/27/2022 at 11:29 a.m., with the Infection Prevention (IP), IP stated medication rooms were cleaned every day. IP stated personal items are not to be stored in there as the medication rooms are only for medications. IP stated there was also a concern for cross contamination if personal items are in the medication room, it can be a risk for infection control.
A review of facility's policy and procedure titled Storage of Medications, revised 4/2022, indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
A review of the facility's policy and procedure titled Infection Prevention and Control Program, revised 4/2022, indicated an infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dignity and respect for three of six sampled ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dignity and respect for three of six sampled residents (Resident 66, 88, and 364) when:
1. Certified Nursing Assistant (CNA 6) was observed standing over Resident 66 while assisting her with her meal.
2. For Resident 88, facility failed to accommodate resident's toileting needs.
3. For Resident 364, facility failed to ensure staff did not speak in another language to each other in front of a resident who could not understand the language.
These deficient practices had the potential to affect residents' sense of self-worth and self-esteem.
Findings:
a. A review of Resident 66's Face Sheet indicated the resident was readmitted to facility on 6/02/2018, with diagnoses that included epilepsy (a central nervous system [neurological] disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness.), type 2 diabetes mellitus with other circulatory complications (chronic condition that affects the way the body processes blood sugar [glucose]), and muscle wasting and atrophy (decrease in size of an organ or tissue; wasting).
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/9/2022, indicated Resident 66 had the ability to make self-understood and understood others sometimes. The MDS indicated Resident 66 required extensive assistance with eating and total dependence with bed mobility transfer and toilet use.
A review of care plan, revised on 5/04/2021, indicated Resident 66 had Activities of Daily Living (ADL) self-care performance deficit need of extensive assist in most ADL's incontinent of bowel and bladder, poor bed mobility, multiple complex condition. The care plan's interventions include assisting with meals, offering fluids during meals, and monitoring resident's functional level daily and report changes.
A review of Resident 66's Order Summary Report, dated 4/22/2022, indicated the resident was to receive no added salt diet pureed texture (smooth liquid) with regular liquids consistency.
During a concurrent observation and interview, on 10/24/2022 at 12:58 p.m., Resident 66 was sitting in bed with the bed in lowest position with CNA 4 standing over resident while assisting her with her. There was no chair observed in the room. CNA 4 stated there were no available chairs. CNA 4 stated she was not aware that not being eye level was an issue with dignity.
During an interview, on 10/27/2022 at 11:01 a.m., the Director of Nursing (DON) stated if staff were looking down on the resident it could affect the resident negatively and make them feel inferior.
b. A review of Residents 88's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included seizures (burst of uncontrolled electrical activity between brain cells [also called neurons or nerve cells] that causes temporary abnormalities in muscle tone or movements [stiffness, twitching or limpness], behaviors, sensations, or states of awareness) age related osteoporosis without current pathological fracture (disorder characterized by reduced bone mass, with a decrease in cortical thickness and in the number and size of the trabeculae of cancellous bone [but normal chemical composition], resulting in increased fracture incidence), and chronic pain syndrome.
A review of the MDS, dated [DATE], indicated Resident 88 had the ability to make self-understood and understand others. The MDS indicated Resident 88 required extensive assistance with bed mobility, and toilet use.
During a concurrent observation and interview, on 10/26/2022 at 11:52 a.m., Resident 88 was lying in bed. Resident 88 stated she needed a wheelchair and had not gotten one and or bedside commode. Resident 88 stated the staff just placed her in a diaper because they did not want to deal with getting her up, she felt like she was being kept in her room, restrained, and felt she had no dignity. Resident 88 stated she was able to transfer herself from her bed to the wheelchair to the toilet on her own but was not able to since being in the facility.
During an interview, on 10/27/2022 at 11:08 a.m., the Director of Nursing (DON) stated there is a concern for her dignity if she was able to use bathroom and now must use diapers it could affect the way she felt.
During a concurrent interview and record review, on 10/28/2022 at 9:40 a.m., the DON reviewed Resident 88's Bowel and Bladder Assessment. The DON stated toilet training was done if the resident had a potential of being able to use the restroom. DON stated if Resident 88 could benefit from toilet training there would be a dignity issue of her not being offered toilet training to maintain her independence to use the restroom.
C. A review of Resident 364's Face Sheet indicated the facility admitted the resident on 10/10/2022 with diagnoses that included multiple sclerosis (a potentially disabling disease of the brain and spinal cord), adult failure to thrive (decline seen in older adults), and paraplegia (inability to voluntarily move the lower parts of the body).
A review of Resident 364's MDS, dated [DATE], indicated the resident had intact cognition (thought processes) and was totally dependent on staff for bed mobility, toilet use, and personal hygiene.
During an interview, on 10/24/2022 at 10:26 a.m., Resident 364 stated the nurses sometimes spoke Spanish around her, and it made her feel like they were talking about her.
During an interview, on 10/27/2022 at 11:38 a.m., the Director of Staff Development (DSD) stated that if a resident preferred to speak in a specific language, then the staff could speak to them in that language. The DSD stated if the resident could not speak a certain language, then it would be disrespectful of the nurses to speak in another language because the resident might think he/she was being talked about.
A review of the facility's policy titled Assisted with Meals revised in 4/2022 indicated residents shall receive assistance with meal in a manner that meets the individual needs of each resident. 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.
A review of the facility's policy titled Quality of Life-Dignity last revised on 4/2022 indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Deeming practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, promptly responding to a resident's request for toileting assistance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an interview, on 10/24/2022 at 9:39 a.m., Resident 20 stated he had a major concern the shower room call lights did no...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an interview, on 10/24/2022 at 9:39 a.m., Resident 20 stated he had a major concern the shower room call lights did not function properly in the shower rooms. Resident 20 stated the shower room call light switch needed to be flipped upward to alert staff. Resident 20 stated if a resident had fallen and was on the ground and wanted to pull the call light, the call light would not function since the call light had to be flipped upward from a standing position.
During an observation and interview with the Maintenance Supervisor (MS), on 10/24/2022 at 11:29 a.m., in Station 2's shower rooms one and two; Station 3's shower rooms [ROOM NUMBERS]; and Station 4 shower rooms' 1 and 2, was observed to have a call light switch that needed to be flipped upward to alert staff. The MS stated the correct way to arrange the call light was for the call light switch to be flipped downward to alert staff. The MS stated this was needed so that residents could safely call nursing staff if they were on the floor.
A review of the policy, Answering the Call Light, last revised April 2022, indicated the purpose of answering the call light is to respond to the resident's requests and needs. The policy indicated for staff to explain the call light to the resident and to demonstrate the use of the call light. The policy indicated to report all defective call lights to the nurse supervisor promptly.
Based on observation, interview, and record review, the facility failed the following:
1. Ensure staff answered residents' call lights (a device used by a patient to signal his or her need for assistance from professional staff) in a timely manner for three (Residents 364, 365, and 47) of six sampled residents.
2. Ensure call lights were within reach for three (Residents 72, 17, and 54) of six sampled residents.
3. Ensure staff answered call lights for nine sampled residents (Residents 6, 18, 20, 37, 50, 64, 73, 74, and 89) from the Resident Council Interview (resident council meeting).
4. Ensure facility provided reasonable accommodation of residents' needs when six of eight shower rooms observed did not have the call light within residents' reach.
These deficient practices had the potential to delay the provision of nursing care to meet the residents' needs safely in a manner that promotes each resident's physical, mental, and psychosocial well-being.
Findings:
1.a. A review of Resident 364's admission Record indicated the facility admitted the resident on 10/10/2022 with diagnoses that included multiple sclerosis (a potentially disabling disease of the brain and spinal cord), adult failure to thrive (decline seen in older adults), restless leg syndrome (a condition that causes an uncontrollable urge to move the legs), and paraplegia (inability to voluntarily move the lower parts of the body).
A review of Resident 364's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/14/2022, indicated the resident had intact cognition (thought processes) and was totally dependent on staff for bed mobility, toilet use, and personal hygiene.
On 10/24/2022 at 10:26 a.m., during an interview, Resident 364 stated her call light (a device used by a patient to signal his or her need for assistance from professional staff) was not within reach sometimes. Resident 364 stated she sometimes had to ask her roommate to call the nurse for her. Resident 364 stated it usually takes staff about 30 minutes to answer the call light.
A review of Resident 364's care plan (contains relevant information about a patient's diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan), initiated on 10/13/2022, indicated the resident is at risk for falls related to being non-ambulatory (not able to walk around), paraplegia, restless leg syndrome, and requiring assistance with activities of daily living (ADLs - activities related to personal care). The goal indicated that the resident's risk for falls will be minimized by the review date. Among some of the interventions listed was to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
1.b. A review of Resident 365's admission Record indicated the facility admitted the resident on 10/11/2022 with diagnoses that included acute kidney failure (when the kidneys stop working suddenly), generalized muscle weakness, and syncope (fainting) and collapse.
A review of Resident 365's Minimum Data Set (a standardized assessment and care screening tool), dated 10/15/2022, indicated the resident had moderately impaired cognition (thought processes) and required extensive assistance from staff for bed mobility, transfers, walking in the room, locomotion on the unit, dressing, toilet use, and personal hygiene.
On 10/24/2022 at 12:42 p.m., during an interview, Resident 365 stated that nurses never came in to check up on her if her daughter was not present. Resident 365 stated she uses her call light (a device used by a patient to signal his or her need for assistance from professional staff) at night because she usually needs help going to the bathroom. Resident 365 stated it takes staff a long time to answer the call lights. Resident 365 stated she has had to get up by herself to go to the bathroom.
A review of Resident 365's care plan (contains relevant information about a patient's diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan), initiated on 10/12/2022, indicated the resident is at risk for falls related to deconditioning (a complex process of physiological change following a period of inactivity, bedrest, or sedentary lifestyle). The goals indicated that the resident's risk for falls will be minimized by the review date, and the resident will be free of minor injury through the review date. Among some of the interventions listed was to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
1.c. A review of Resident 47's admission Record indicated the facility originally admitted the resident on 11/11/2021 and readmitted the resident on 12/18/2021 with diagnoses that included radiculopathy in the lumbar region (an inflammation of a nerve root in the lower back), morbid obesity (a complex chronic condition in which a person has a body mass index [measure of body fat based on height and weight] of 40 or higher), difficulty in walking, and muscle wasting and atrophy (loss of muscle tissue).
A review of Resident 47's Minimum Data Set (MDS - a standardized assessment and care screening tools), dated 8/19/2022, indicated the resident had intact cognition (thought process) and required extensive assistance from staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene.
On 10/24/2022 at 11:51 a.m., during an interview, Resident 47 stated she had to wait at least 15 to 20 minutes for staff to answer her call light (a device used by a patient to signal his or her need for assistance from professional staff).
A review of Resident 47's care plan (contains relevant information about a patient's diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan), initiated on 11/11/2021, indicated the resident was at risk for falls an injury related to gait (a person's pattern of walking)/balance problems, psychoactive drug (affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) use, and chronic back pain. The goal indicated that the resident will be free of minor injury through the review date. Another goal indicated that the resident will not sustain serious injury through the review date. Among some of the interventions listed was to be sure that the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
2.a. A review of Resident 72's admission Record indicated the facility originally admitted the resident on 6/11/2021 and readmitted the resident on 3/19/2022 with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or inability to move one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting the left non-dominant side, ataxia (poor muscle control that causes clumsy voluntary movements), and muscle wasting and atrophy (loss of muscle tissue).
A review of Resident 72's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/15/2022, indicated the resident had severely impaired cognition (thought process) and required extensive assistance from staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene.
On 10/24/2022 at 11:37 a.m., during an observation, observed Resident 72 asleep in bed. The resident's call light (a device used by a patient to signal his or her need for assistance from professional staff) was on the floor not clipped to the bed.
On 10/24/2022 at 11:47 a.m., during a concurrent observation and interview, the Assistant Director of Nursing (ADON) confirmed the resident's call light was on the floor and stated it should have been clipped to the resident's pillow so it would be within the resident's reach in case she needed to call for help.
A review of Resident 72's care plan (contains relevant information about a patient's diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan), initiated on 6/12/2021, indicated the resident was at risk for falls related to deconditioning (a complex process of physiological change following a period of inactivity, bedrest, or sedentary lifestyle) and unsteady gait (a person's pattern of walking). The goal indicated that the resident will minimize the risk of falls through the review date. Among some of the interventions listed was to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
A review of Resident 72's care plan, initiated on 6/14/2021, indicated the resident had an alteration in musculoskeletal status related to vitamin D deficiency (can cause issues with bones and muscles) and is at risk for pain, joint limitations, and fractures. The goal indicated that the resident will remain free of injuries or complications related to vitamin D deficiency through the review date. Among some of the interventions listed was to ensure the call was within reach and respond promptly to all requests for assistance.
2.b. A review of Resident 17's admission Record indicated the facility originally admitted the resident on 8/1/2022 and readmitted the resident on 10/6/2022 with diagnoses that included generalized muscle weakness and abnormalities of gait (a person's pattern of walking) and mobility.
A review of Resident 17's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/8/2022, indicated the resident had severely impaired cognitive (thought process) skills for daily decision making. The MDS indicated the resident was totally dependent on staff for eating and personal hygiene, and required extensive assistance for bed mobility, transfers, dressing, and toilet use.
On 10/24/2022 at 9:46 a.m., during an observation, observed Resident 17 asleep in bed. The resident's bed was in the lowest position. Observed resident's call light (a device used by a patient to signal his or her need for assistance from professional staff) wrapped around the overhead lamp, not within the resident's reach.
On 10/24/2022 at 9:58 a.m., during a concurrent observation and interview, Registered Nurse 2 (RN 2) unwound the resident's call light from the overhead lamp and stated that the resident's call light was not within reach. RN 2 stated it should have been within the resident's reach in case the resident needed something.
A review of Resident 17's care plan (contains relevant information about a patient's diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan), initiated on 8/10/2022, indicated the resident had a communication problem related to a language barrier; French is the resident's primary language. One of the goals indicated that the resident will be able to make basic needs known on a daily basis through the review date. Among some of the interventions listed was to ensure/provide a safe environment: Call light in reach, adequate light, bed in lowest position and wheels locked, and avoid isolation.
2.c. A review of Resident 54's admission Record indicated the facility originally admitted the resident on 5/11/2017 and readmitted the resident on 9/5/2021 with diagnoses that included muscle wasting and atrophy (loss of muscle tissue) and adult failure to thrive (decline seen in older adults).
A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/18/2022, indicated the resident had severe impairment in cognition (thought process) and required extensive assistance from staff for bed mobility, dressing, eating, toilet use, and personal hygiene.
On 10/24/2022 at 10:57 a.m., during an observation, observed Resident 54 asleep in bed. The resident's call light (a device used by a patient to signal his or her need for assistance from professional staff) was wrapped around the side rail near the bed frame, underneath the mattress.
On 10/24/2022 at 11:07 a.m., during a concurrent observation and interview, Certified Nursing Assistant 5 (CNA 5) confirmed that the resident's call light was under the resident's mattress and stated the resident's call light should have been within reach in case of emergencies.
A review of Resident 54's care plan (contains relevant information about a patient's diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan), initiated on 4/22/2019, indicated the resident was at high risk for falls related to poor communication/comprehension, unawareness of safety needs, impaired cognitive function, impaired decision-making, and further aggravated by the following diagnoses: Use of low air loss mattress (LAL - a mattress designed to prevent and treat pressure wounds) and use of mechanical lift machine (device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone). One goal indicated that the resident will not sustain a fall-related injury through the review date. Another goal indicated that the resident's risk for falls and fall-related injuries will be minimized with interventions through the review date. Among some of the interventions listed was to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
A review of Resident 54's care plan, initiated on 6/21/2019, indicated the resident has bowel incontinence related to immobility, impaired cognition/communication, and the aging process. The care plan indicated the resident was at risk for skin breakdown, urinary tract infection (UTI - an infection in any part of the urinary system), and its complications. The goal indicated that the resident will remain free from skin breakdown due to incontinence and brief use through the review date. Among some of the interventions listed was to place call light within reach.
A review of Resident 54's care plan, initiated on 12/7/2018, indicated the resident has a history of a right femur (thigh bone) fracture (a break in the bone) related to a fall. The care plan indicated the resident is at risk for pain/discomfort, decline in mobility, repeated falls/injury and its complications. The goal indicated that the resident will remain free of complications related to a fracture through the review date. Among some of the interventions listed was to anticipate the residents needs and ensure the call light is within reach.
On 10/26/2022 at 4:16 p.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated the Director of Staff Development (DSD) provided in-services (training intended for those actively engaged in a profession or activity) regarding call light. CNA 2 stated they are taught to answer call lights as soon as possible. CNA 2 stated that call lights should also be within easy reach of the resident. CNA 2 stated if the resident's assigned CNA was not available to answer the call light, then someone else should answer it. CNA 2 stated it is important to attend to the resident's needs right away because you do not know if the resident is having an emergency.
On 10/27/2022 at 11:38 a.m., during an interview, the DSD stated she provided her staff with in-services regarding call lights. The DSD stated she taught them to make sure that call lights are answered in a timely manner and to make sure call lights are within reach of the resident and not on the floor. The DSD stated it was important to answer call lights timely to prevent falls or injuries. The DSD stated it was also important because the resident could be in distress or pain. The DSD stated if the resident needed anything, they we would not want them to wait.
On 10/27/2022 at 11:54 a.m., during an interview, the Director of Nursing (DON) stated he tells his staff that everyone should be answering call lights as soon as possible. The DON stated it was important to do this so that residents' needs could be met timely. The DON stated it was also important because the resident's needs may be an emergency.
A review of the facility's policy and procedures titled, Answering the Call Light, last revised in 4/2022, indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Answer the resident's call as soon as possible.
3. During the Resident Council Interview (resident council meeting) on 10/25/2022 at 10:30 a.m., nine of ten sampled residents (Resident 6, 18, 20, 37, 50, 64, 73, 74, 89) complained staff were not answering their call lights. The residents reported it took from thirty minutes to one hour to receive necessary care, including being changed.
3.a. A review of Resident 6's Face Sheet indicated the facility admitted the resident on 6/29/2020 with diagnoses that included stroke (damage to tissues in the brain due to a loss of oxygen to the area) and epilepsy (seizure (a brain disorder that can cause people to suddenly become unconscious and have violent, uncontrolled movements of the body).
A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/07/2022, indicated Resident 6 is cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 6 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, toilet use, and personal hygiene.
A review of Resident 6's Falls Care Plan, initiated 7/01/2020, indicated a goal that Resident 6 will minimize the risk of falls through the review date. One of the interventions indicated was to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan indicated Resident 6 needs prompt response to all requests for assistance.
A review of the Resident Council Meeting Minutes, dated 9/07/2022, indicated Resident 6 complained that call lights were not answered in a timely manner. The Minutes indicated there was an in-service given by the DSD on 10/10/2022 for Call Light Response.
3.b. A review of Resident 18's Face Sheet indicated the facility admitted the resident on 7/30/2021 with a diagnosis of Parkinson's disease (a progressive disease of the nervous system with symptoms such as tremor, muscular rigidity, and slow, movement)
A review of Resident 18's MDS, dated [DATE], indicated Resident 18 is moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 18 required one-person extensive assistance with bed mobility, transfer, toilet use, and personal hygiene.
A review of Resident 18's Falls Care Plan, initiated 8/02/2021, indicated a goal that Resident 18 will be free of minor injury through the review date. One of the interventions indicated was to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan indicated Resident 18 needs prompt response to all requests for assistance.
3.c. A review of Resident 20's Face Sheet indicated the facility admitted the resident on 11/09/2021 with a diagnosis of chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs).
A review of Resident 20's MDS, dated [DATE], indicated Resident 20 is cognitively intact with skills required for daily decision making. The MDS indicated Resident 20 required setup help only supervision (oversight, encouragement or cueing) with bed mobility, transfer, toilet use and walking.
A review of Resident 20's Falls Care Plan, initiated 11/10/2021, indicated a goal that Resident 20 will be free of minor injury through the review date. One of the interventions indicated was to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan indicated Resident 20 needs prompt response to all requests for assistance.
During an observation and interview with Resident 20 on 10/24/22 at 9:39 a.m., he stated he has had to wait at least 30 minutes for his call light to be answered. Resident 20 stated he has had pain and this is a concern if he has to wait a long time for his pain medication.
3.d. A review of Resident 37's Face Sheet indicated the facility admitted the resident on 10/13/2020 with diagnoses that included epilepsy and history of falling.
A review of Resident 37's MDS, dated [DATE], indicated Resident 37 is cognitively intact with skills required for daily decision making. The MDS indicated Resident 37 required one-person extensive assistance with bed mobility, dressing, transfer, toilet use, and personal hygiene.
A review of Resident 37's Falls Care Plan, initiated 12/15/2020, indicated a goal that Resident 37 will minimize the risk of falls through the review date. One of the interventions indicated was to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan indicated Resident 37 needs prompt response to all requests for assistance.
3.e. A review of Resident 50's Face Sheet indicated the facility admitted the resident on 6/29/2020 with diagnoses that included syncope (fainting), difficulty in walking, and history of fall.
A review of Resident 50's MDS, dated [DATE], indicated Resident 50 is cognitively intact with skills required for daily decision making. The MDS indicated Resident 50 required one-person extensive assistance with bed mobility, transfer, toilet use, and personal hygiene.
A review of Resident 50's Falls Care Plan, initiated 9/03/2020, indicated a goal that Resident 50 will be free of minor injury through the review date. One of the interventions indicated was to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan indicated Resident 50 needs prompt response to all requests for assistance.
3.f. A review of Resident 64's Face Sheet indicated the facility admitted the resident on 4/13/2018 with a diagnosis of history of falling.
A review of Resident 64's MDS, dated [DATE], indicated Resident 64 is cognitively intact with skills required for daily decision making. The MDS indicated Resident 64 required one-person extensive assistance with bed mobility, transfer, dressing and toilet use.
A review of Resident 64's Falls Care Plan, initiated 9/30/2018, indicated a goal that Resident 64 will minimize the risk of falls through the review date. One of the interventions indicated was to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan indicated Resident 64 needs prompt response to all requests for assistance.
3.g. A review of Resident 73's Face Sheet indicated the facility admitted the resident on 4/13/2018 with diagnoses that included hypertension (high blood pressure) and diabetes mellitus (high blood sugar(a condition that affects how the body uses blood sugar [glucose]).
A review of Resident 73's MDS, dated [DATE], indicated Resident 73 is cognitively intact with skills required for daily decision making. The MDS indicated Resident 73 required one-person extensive assistance with transfer and toileting.
A review of Resident 73's Falls Care Plan, initiated 8/07/2020, indicated a goal that Resident 73 will be free of falls through the review date. One of the interventions indicated was to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan indicated Resident 73 needs prompt response to all requests for assistance.
3.h. A review of Resident 74's Face Sheet indicated the facility admitted the resident on 9/11/2018 with a diagnosis of history of falling.
A review of Resident 74's MDS, dated [DATE], indicated Resident 74 is cognitively intact with skills required for daily decision making. The MDS indicated Resident 74 required one-person extensive assistance with walking, dressing, and personal hygiene.
A review of Resident 74's Falls Care Plan, initiated 10/22/2018, indicated a goal that Resident 74 will minimize the risk of falls through the review date. One of the interventions indicated was to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan indicated Resident 74 needs prompt response to all requests for assistance.
3.i. A review of Resident 89's Face Sheet indicated the facility admitted the resident on 10/03/2018 with diagnoses that included diabetes and hypertension.
A review of Resident 89's MDS, dated [DATE], indicated Resident 89 is cognitively intact with skills required for daily decision making. The MDS indicated Resident 89 required one-person limited assistance with bed mobility, transfer, dressing and toilet use.
A review of Resident 89's Falls Care Plan, initiated 10/17/2019, indicated a goal that Resident 89 will minimize the risk of falls through the review date. One of the interventions indicated was to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan indicated Resident 89 needs prompt response to all requests for assistance.
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** d. A review of Resident 93's Face Sheet indicated the facility originally admitted the resident, on 3/29/2022 and readmitted on ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. A review of Resident 93's Face Sheet indicated the facility originally admitted the resident, on 3/29/2022 and readmitted on [DATE], with diagnosis that included type 2 diabetes mellitus (a condition that affects the way the body regulates and uses blood sugar), chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing related problems), and end stage renal (kidneys) disease dependent on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).
A review of Resident 93's MDS, dated [DATE] indicated the resident had moderate cognitive (thinking or mental processes) impairment (damaged or is not working properly). The MDS indicated Resident 93 required total assistance with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing.
A review of Resident 93's History and Physical (H&P), dated 9/27/2022, indicated the resident did not have the capacity to understand and make decisions.
During a concurrent interview and record review, on 10/26/2022 at 3:37 p.m., the Social Services Director (SSD) stated IDT care plan conference was done within 48 hours of admission, readmission, quarterly, annually, or significant change of condition. The SSD stated the purpose of IDT meeting was to review a resident's plan of care with different departments including nursing, social services, activities, rehabilitation, dietary, case management, resident or resident representative, and physician if requested. The SSD stated Resident 93 did not have an IDT meeting but should have had one between 9/26/2022 to 9/28/2022. The SSD stated when IDT meeting was not done, there was a potential for not identifying issues and not being able to address the resident's needs such as diet, insurance, activities, things that the resident likes and dislikes, and psychosocial needs. The SSD stated social services department was responsible for scheduling the meeting.
During an interview, on 10/27/2022 at 3:51 p.m., the Social Services Assistant (SSA) stated a significant change of condition assessment was endorsed to her by the MDS department, but it slipped her mind and did not schedule a meeting. The SSA stated the absence of IDT care plan meeting had a potential to cause discrepancies within different departments if there were any changes in the resident's condition.
During a concurrent interview and record review, on 10/28/2022 at 8:54 a.m., DON stated there was no IDT meeting for Resident 93 after a significant change of condition assessment on 10/5/2022. The DON stated there should have been an IDT meeting on 10/13/2022. The DON stated the absence of IDT meeting had the potential to affect the resident's care because information was not passed on within the resident's care team. DON stated the last IDT meeting was on 7/29/2022.
During a concurrent interview and record review, on 10/28/2022 at 9:10 a.m., the MDS Nurse (MDSN) stated even though there was a care plan revision on 10/7/2022, it did not include the family to discuss Resident 93's current conditions and plan of care when the resident was readmitted .
A review of the facility's policy and procedure (P&P), dated 4/2022, titled, Care Plans, Comprehensive Person-Centered, 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. 1. 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 . 3. The IDT includes the attending physician, a registered nurse who has responsibility for the resident, a nurse aide who has responsibility for the resident, a member of the food and nutrition services, the resident and the resident's legal representative (to the extent practicable), and other appropriate staff or professionals as determined by the resident's needs or as requested by the resident. 4. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to participate in the planning process, identify individuals or roles to be included . 6. An explanation will be included in a resident's medical record if the participation of the resident and his/her resident representative for developing the resident's care plan is determined to not be practicable. 7. The care planning process will facilitate resident and/or representative involvement . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment .
c. A review of Resident 77's Face Sheet indicated the resident was admitted to the facility, on 4/18/2022, with diagnoses that included dementia (decline in mental ability severe enough to interfere with daily functioning/life), abdominal aortic aneurysm (a bulge or swelling in the aorta, the main blood vessel that runs from the heart down through the chest and abdomen), and malignant neoplasm of lung (a cancer that begins in the lungs).
A review of Resident 77's MDS, dated [DATE], indicated the resident was cognitively intact. The MDS indicated the resident needed one-to-two-person assistance with bed mobility, transfer, walking in corridor, locomotion, dressing, eating, toilet use and personal hygiene.
A review of Resident 77's weight monitoring indicated the following:
1. On 5/21/22, Resident 77 weighed 136 lbs.(pounds).
2. On 6/2/22, Resident 77 weighed 133 lbs.
3. On 7/8/22, Resident 77 weighed 130 lbs.
4. On 9/7/22, Resident 77 weighed 116 lbs.
5. On 9/12/22, Resident 77 weighed 112 lbs.
6. On 10/7/22, Resident 77 weighed 111 lbs.
7. On 10/13/22, Resident 77 weighed 109 lbs.
8. On 10/20/22, Resident 77 weighed 106 lbs.
A review of Resident 77's care plan for malnutrition (possible weight loss), initiated on 4/19/2022 and revised 5/1/2022, indicated no changes made until it was resolved on 9/1/2022.
During an interview, on 10/27/2022 at 10:18 a.m., DON stated the facility's weight variance meeting included Change of Condition (COC) and care plan was revised.
A review of Nutrition-Quarterly Assessment, dated 10/11/2022, indicated Resident 77 was eating 75-100% of meals and was meeting care plan goals. There was no documented evidence of quarterly assessment done prior to 10/11/2022. The initial weight variance meeting was attended by Registerd Dietitian (RD), Activities Director (AD), Social Services Assistant (SSA) and Quality Assurance (QA).
During an interview, on 10/27/2022 at 2:44 p.m., QA stated initial care plan was done by admitting nurse and followed up by QA. QA stated the MDS reviews the care plans after comprehensive assessment, quarterly and annual.QA stated the Interdisciplinary Team (IDT) meetings should include the resident. When asked why the IDT was dated 10/11/2022 and signed off by participants between 10/24/2022 and 10/26/2022, QA stated that sign off was when the participants signed the IDT meeting.
During an interview, on 10/27/2022 at 2:52 p.m. the MDS Coordinator stated the care plan for Risk for weight loss was resolved 9/1/2022. The MDS Coordinator stated the care plan for malnutrition initiated on 4/19/2022 was still outstanding as it was revised 7/5/2022. MDS Coordinator stated the resident's care plan did not indicate to contact the physician. MDS Coordinator stated the care plan should indicate to contact the physician. MDS Coordinator was unable to answer why the care plan was titled Malnutrition (possible weight loss), and risk for weight loss when the resident was actively losing weight on monthly and weekly monitoring.
During an interview, on 10/28/2022 9:28 a.m., DON stated there was no care plan. DON stated that the IDT on 10/11/22 was only attended by RD and Activities Director as they were the only ones that signed that day. DON stated weight variance was sort an IDT meeting of weight loss and nursing should be involved.
A review of the facility's policy and procedure titled, Care Planning-Interdisciplinary Team, revised 4/2022, indicated that a comprehensive care plan for each resident is developed within 7 days of completion of the resident assessment. The resident, Resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.
Based on interview and record review, the facility failed to:
1. Ensure a care plan (contains relevant information about a patient's diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan) was developed addressing a resident's refusal of restorative nursing assistant (RNA - responsible for following a resident care plan in helping residents with range of motion [the capability of a joint to go through its complete spectrum of movements]) exercises for one (Resident 47) out of 26 sample residents investigated for comprehensive care plans.
2. Ensure a care plan was developed addressing a resident's preference to use an adult incontinence pad (a small, impermeable multi-layered sheet with high absorbency used as a precaution against fecal or urinary incontinence [loss of bowel and/or bladder control]) instead of a bedpan (a receptacle used for the toileting of a bedridden patient in a health care facility) for one (Resident 47) out of 26 sample residents investigated for comprehensive care plans.
3. Ensure that care plan for weight loss was continued and revised quarterly or as needed for one of one sampled resident (Resident 77).
4. Ensure an interdisciplinary team (IDT) comprehensive care plan meeting was held with a resident and resident representative participation for one of one sampled resident (Resident 93).
5. Ensure Morphine Sulfate (a drug used to treat moderate to severe pain) was administered as per order and conduct pain assessment before and after administration of pain medication as indicated the care plan 6.for one of one sampled resident (Resident 91) investigated under the care area pain management.
6. Ensure Resident 5 who had a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) was provided catheter care consistently based on the care plan for at risk for catheter- related trauma and sign and symptoms of urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra) for one of four sampled resident (Resident 5) investigated under the care area Urinary Catheter (urinary catheter is a flexible tube used to empty the bladder and collect urine in a drainage bag).
These deficient practices had the potential to result in failure to deliver the necessary care and services that were not person-centered and not reflective of residents' current goals to attain or maintain their highest practicable well-being.
Findings:
a. A review of Resident 47's Face Sheet indicated the facility originally admitted the resident, on 11/11/2021 and readmitted the resident on 12/18/2021, with diagnoses that included radiculopathy in the lumbar region (an inflammation of a nerve root in the lower back), morbid obesity (a complex chronic condition in which a person has a body mass index of 40 or higher), difficulty in walking, and muscle wasting and atrophy (loss of muscle tissue).
A review of Resident 47's Minimum Data Set (MDS - a standardized assessment and care screening tools), dated 8/19/2022, indicated the resident had intact cognition (thought process) and required extensive assistance from staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene.
During a concurrent interview and record review, on 10/26/2022 at 11:07 a.m., Registered Nurse 2 (RN 2) stated according RNA Treatment Record, Resident 47 had been refusing her RNA exercises. RN 2 stated she did not find a care plan addressing the resident's refusal of her exercises.
During a concurrent interview and record review, on 10/27/2022 at 8:33 a.m., RN 3 stated Resident 47 had a physician's order, ordered on 3/2/2022, for active assisted range of motion (AAROM - resident uses the muscles around a weak joint to complete stretching exercises with the help of a physical therapist or restorative nursing assistant) exercises for bilateral (both sides) lower extremities every day, five times a week, as tolerated.
During an interview, on 10/27/2022 at 11:54 a.m., the Director of Nursing (DON) stated the resident's refusal of RNA exercises should have been care planned so that all disciplines were aware of the resident's preferences.
A review of the facility's policy and procedures titled, Care Plans, Comprehensive Person-Centered, last revised in 4/2022, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will describe services that would otherwise be provided for the resident but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.
b. During a concurrent observation and interview, on 10/24/2022 at 11:51 a.m., Resident 47 was awake in bed. Resident 47 stated she was incontinent (loss of bowel and/or bladder control) but the facility would not provide her with adult incontinence pads because they wanted her to use a bedpan (a receptacle used for the toileting of a bedridden patient in a health care facility). Resident 47 stated she did not want to use a bedpan because she could not feel when she had to use the bathroom. Resident 47 stated she was also on medications that made her urinate all the time.
During an interview, on 10/26/2022 at 9:57 a.m., Certified Nursing Assistant (CNA 7) stated they only gave her incontinence pads at night because the physician ordered for the resident to use a bedpan during the day.
A review of Resident 47's Order Summary Report (summary of resident's physician's orders) indicated a physician's order, dated 10/18/2022, that the resident may use a bedpan for toileting as needed (PRN) per request.
During a concurrent interview and record review, on 10/26/2022 at 10:30 a.m., RN 2 stated if the resident did not want to use a bedpan, then the facility should go with the resident's preferences. RN 2 stated she did not find a care plan addressing the resident's preference to use an adult incontinence pad over a bedpan.
On 10/27/2022 at 11:38 a.m., during an interview, the Director of Staff Development (DSD) stated staff should follow the resident's preferences because the resident had the right to make decisions. The DSD stated the resident's preferences should be care planned when the resident had a specific preference.
During an interview, on 10/27/2022 at 11:54 a.m., the DON stated the facility did their best to honor the resident's preferences when it came to activities of daily living care. The DON stated if a resident had a specific preference, then it should be care planned because it was important to honor the resident's preferences since he/she relied on the nurses for assistance.
A review of the facility's policy and procedures titled, Care Plans, Comprehensive Person-Centered, last revised on 4/2022, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will reflect the resident's expressed wishes regarding care and treatment goals.
e. A review of Resident 91`s Face Sheet indicated the facility admitted the resident on 9/07/2022 with diagnoses that included chronic muscle weakness, gastro-esophageal reflux disease (digestive disease in which stomach acid or bile irritates the food pipe lining) and dementia.
A review of Resident 91's MDS, dated [DATE], indicated Resident 40's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 40 required extensive assistance for eating, transfer, dressing, toilet use, and for personal hygiene.
A review of Resident 91`s At Risk for Pain care plan, dated 9/29/2022, indicated an intervention to administer analgesia (pain reliever) as per physician`s orders and to monitor and document for probable cause of each pain episode.
A review of Resident 91`s physician`s order recap, indicated an order for Morphine Concentrate Solution 20 milligram per milliliter (ml), give 0.25 ml sublingually (underneath tongue) every 4 hours as needed for pain and shortness of breath.
During a concurrent interview and record review, on 10/27/22 at 11:11 a.m., of the Controlled Drug Record (CDR), with Assistant Director of Nursing (ADON), the record indicated on 10/23/2022 at 12:23 p.m., Morphine was removed and initialed from the CDR. A review of the Medication Administration Record (MAR) indicated there was no documentation that Morphine was given on this date and time. The ADON stated the nurses` giving the medication should have documented the administration of Morphine and conduct a pain assessment before and after giving the medication to ensure efficacy of the pharmacologic intervention. ADON stated if the MAR did not show the medication was administered, then it was not administered and the resident could have suffered from unrelieved pain.
A review of the facility`s policy and procedure dated 4/2022, titled Pain- Clinical Protocol, indicated that the staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern and severity.
A review of the facility`s policy and procedure dated 4/2022, titled Care Plans, Comprehensive Person-Centered, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to met the resident`s physical, psychosocial and functional needs is developed and implemented for each resident.
f. A review of Resident 5`s Face Sheet indicated the resident was originally admitted to the facility, on 10/02/20219 and readmitted on [DATE], with diagnoses that included benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty), dementia (a group of thinking and social symptoms that interferes with daily functioning), personal history of malignant neoplasm of epididymis (), and unspecified intellectual disabilities (a broad category of disorders characterized by an impairment to the intelligence an individual possesses).
A review of Resident 5's MDS, dated [DATE], indicated Resident 5 had the ability to sometimes makes self-understood and ability to sometimes understand others. The MDS indicated that Resident 5 required extensive assistance for transfer, dressing, toilet use, personal hygiene, bathing and limited assistance with eating.
A review of Resident 5`s physician`s order indicated the resident was to receive catheter care every shift, dated 4/18/2022 and reordered on 8/21/2022.
During an interview and record review, on 10/27/22 at 9:25 a.m., ADON stated in the Treatment Administration Record (TAR), there were multiple days that catheter care were not provided as evidenced by blank sections of the TAR.
A review of the TAR reviewed for the months of 7/2022, 9/2022, and 10/2022 indicated there were no treatment provided for the following dates:
1. July 6, 2022; 7-3 shift (7:00 a.m.- 3:00 p.m.)
2. July 6, 7, 11, 13, and 17, 2022; 3-11 shift (3:00 p.m.-11:00 p.m.)
3. July 19 and 29, 2022; 11-7 shift (11:00 p.m.- 7:00 a.m.)
4. October 8, 14, and 15, 2022; 3-11 shift.
5. October 8, 12,13,15,16,23, and 24, 2022; 11-7 shift.
The ADON stated if catheter care wass not provided consistently it could result to accumulation of sediments and clogging which could lead to infection and hospitalization.
During an interview, on 10/27/22 at 9:28 a.m., Treatment Nurse 1 (TRN1) stated catheter care included checking for any dislodgement or clogging, leaking, cleansing the site, checking for sediments in the urine, changing the bag as needed. The TRN stated that this tasks were documented in the TAR. The TRN 1 stated if there was no documentation of the treatment that means there was no treatment provided. TRN 1 stated there was a potential for infection that was why catheter care had to be provided to prevent this.
A review of the facility`s policy and procedure dated 4/2022, titled Care Plans, Comprehensive Person-Centered, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to met 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 F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure one of one observed intravenous (IV - into...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure one of one observed intravenous (IV - into or connected to a vein [a blood vessel that carries blood to the heart]) medication cart (IV Cart) was locked when not in use and unattended.
2. Adhere to medication storage when personal items were found in two out of four medication storage rooms (Medication Storage rooms [ROOM NUMBERS]).
These deficient practices had the potential to place residents' safety at risk by giving residents an opportunity for unsupervised and unnecessary access to medications and had the potential for cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another with harmful effect).
Cross reference to F880
Findings:
a. On 10/25/2022 at 3 p.m., in Nurses Station 1, observed the IV Cart unlocked and unattended. During a concurrent observation and interview, the Assistant Director of Nursing (ADON) stated the IV medication cart was unlocked but should have been locked because there was a risk for residents grabbing what was inside. The ADON stated inside the IV Med Cart 1 were IV medications and IV supplies including IV tubing and normal saline flushes (NS flush - a mixture of salt and water that is used to push any residual medication or fluid through the IV line and into your vein).
A review of the facility's policy and procedure (P&P), dated, 4/2022, titled, Storage of Medications, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls . 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended .
b.1. During a concurrent observation and interview on 10/25/2022 at 1:30 p.m., of Medication Storage 3, observed a case of eyeglasses with eyeglasses in them with no name noted; there was no identifier for who the item belonged to. Licensed Vocational Nurse (LVN 4) stated the pair of eyeglasses should not be in medication room (storage) but should be given to social services department. LVN 4 stated that keeping personal items in the medication storage room can be a risk for infection.
During a concurrent observation and interview on 10/25/2022 at 2:01 p.m., with the Assistant Director of Nursing (ADON), the ADON stated glasses (eyeglasses) do not belong in medication room but should go to social services department; personal belongings do not belong in medication room. The ADON stated it is a risk for infection.
b.2. During a concurrent observation and interview on 10/26/2022 at 10:57 a.m., of the Medication Storage 4, observed a grocery bag with an electrical shaver with no name on who it belonged to. Also observed a grey bin with a glucometer and a life alert vest. LVN 5 stated she does not know why those items were in medication room, but they should have been placed in the social services department.
During a concurrent observation and interview on 10/26/2022 at 11:38 a.m., the ADON stated that personal items in medication room should be given to social services department and should not be stored in the medication room. The ADON stated that items in medication room can be an infection control issue. The ADON also stated if the items belong to residents, it can cause a delay for them to get the needed items.
During an interview on 10/27/2022 at 11:22 a.m., the DON stated no personal items should be in the medication room. The DON stated personal items could be a source of cross contamination. The DON also stated those personal items could be missing from residents.
During an interview on 10/27/2022 at 11:29 a.m., with the Infection Prevention (IP), IP stated medication rooms were cleaned every day. IP stated personal items are not to be stored in there as the medication rooms are only for medications. IP stated there is also a concern for cross contamination if personal items are in the medication room, it can be a risk for infection control.
A review of facility's policy and procedure titled Storage of Medications, revised 4/2022, indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
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 follow safe food handling practices by failing to:
1. Discard eight of eight observed food items (cottage cheese A [Item 1], ...
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Based on observation, interview, and record review, the facility failed to follow safe food handling practices by failing to:
1. Discard eight of eight observed food items (cottage cheese A [Item 1], cottage cheese B [Item 2], sour cream [Item 3], five tuna sandwiches [Item 4, Item 5, Item 6, Item 7, and Item 8]) by their use by (last date recommended for the use of the product) date.
2. Maintain a clean ice machine for one of one observed ice machine.
These deficient practices had placed the residents at risk for foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) with common symptoms such as nausea, vomiting, stomach cramps, and diarrhea.
Findings:
a. During a concurrent observation and interview on 10/24/2022 at 8:26 a.m., in a walk-in refrigerator, Dietary Aide 1 (DA 1) stated the top dates on the sticker labels were the dates the containers were opened by kitchen staff, and the bottom dates were the use by dates. DA 1 stated once a product was opened, they have seven days to use the product and three days to use tuna sandwiches after they were prepared. The following food items were observed:
- Item 1 had a sticker labeled with two dates 10/21/2022 (top date/open date) and 10/28/2022 (bottom date/use by date). The product container itself had a manufacturer's use by date of 10/16/2022. A review of Item 1 indicated the facility opened Item 1 past the manufacturer's use by date. Also observed on the sticker label a previous date written in pen crossed out with one line of a black marker.
- Item 2 had a sticker labeled with two dates 9/26/2022 (top date/open date) and 10/22/2022 (bottom date/use by date). The product container itself had a manufacturer's use by date of 10/16/2022. During a concurrent interview, DA 1 stated Item 2 had been opened for 28 days.
- Item 3 had a sticker labeled with two dates 10/10/2022 (top date/open date) and 10/22/2022 (bottom date/use by date). The product container itself had a manufacturer's use by date of 10/22/2022. During a concurrent interview, DA 1 stated Item 3 had been opened for 14 days.
- Item 4, Item 5, Item 6, Item 7, and Item 8 were in a tray labeled with use by date of 10/23/2022. During a concurrent interview, DA 1 stated they should have thrown away these items.
During an interview on 10/25/2022 at 8:58 a.m., DA 3 stated cottage cheese was used when residents requested fruits and sour cream was used with mashed potatoes.
A review of the facility's menu from 10/2/2022 to 10/24/2022, indicated the facility served fruit cups/fresh fruits/mixed fruits on four occasions (10/3/2022, 10/4/2022, 10/13/2022, and 10/21/2022) and served mashed potatoes/garlic mashed potatoes on four occasions (10/3/2022, 10/10/2022, 10/15/2022, and 10/18/2022).
During an interview on 10/25/2022 at 9:57 a.m., the Registered Dietician (RD) stated tuna sandwiches should be used within 3 days after preparation date. The RD stated when tuna sandwiches were used past the time allowed, they could cause foodborne illnesses and the signs and symptoms are diarrhea, nausea, vomiting, or even fever. RD stated it was important to take extra precautions in the facility because of the population with residents who have comorbidities (the condition of having two or more diseases at the same time).
During an interview on 10/26/2022 at 12:08 p.m., the RD stated the reference guide indicated seven days after opening or follow expiration date whichever comes first for sour cream and cottage cheese. The RD stated the potential risk of using sour cream and cottage cheese beyond the allowed time is the products will turn sour and could make residents sick with diarrhea.
A review of the facility's policy and procedure (P&P), titled, Food Receiving and Storage, dated 4/2022, indicated, Foods shall be received and stored in a manner that complies with safe food handling process . 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .
A review of the facility's P&P, titled, Labeling & Dating, dated 4/2022, indicated, Prepped items: i.e., tuna salad, egg salad, etc. prep date use by date* Refer to Storage Guide for Specific Food Items Use by Date
A review of the facility's P&P, titled, Refrigerated Storage Guide, dated 4/2022, indicated, Cream, yogurt, cottage cheese, cream cheese, sour cream follow expiration date or 7 days after opening, whichever comes first .
b. During a concurrent observation and interview on 10/25/2022 at 10:44 a.m., observed a black-colored material on a white paper towel after swiping on the edges of the ice storage and ice machine lid. DA 2 stated the black material on the paper towel could be dirt and the facility could be serving dirty ice to residents.
During an interview on 10/26/2022 at 12:08 p.m., the RD stated if she were to swipe the ice machine with a white paper towel, there should not be any dirt on the paper towel. The RD stated if there was black on the paper towel, this could be a concern for mildew build up because an ice machine is a moist reservoir. The RD stated the potential problem of a contaminated ice machine was getting residents sick such as diarrhea, vomiting, and nausea.
A review of the facility's ice machine User Manual, titled, Cleaning, Sanitation and Maintenance, dated 7/2006, indicated, It is the User's responsibility to keep the ice machine and ice storage bin in a sanitary condition. Without human intervention, sanitation will not be maintained. Ice machine also require occasional cleaning of their water systems with a specifically designed chemical. This chemical dissolve mineral build-up that forms during the ice making process .
A review of the facility's P&P, titled, Ice Machines and Ice Storage Chests, dated 4/2022, indicated, Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 41% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 6 life-threatening violation(s), Special Focus Facility, 6 harm violation(s), $311,888 in fines, Payment denial on record. Review inspection reports carefully.
- • 182 deficiencies on record, including 6 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $311,888 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Maclay Healthcare Center's CMS Rating?
CMS assigns MACLAY HEALTHCARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Maclay Healthcare Center Staffed?
CMS rates MACLAY HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 41%, compared to the California average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 64%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Maclay Healthcare Center?
State health inspectors documented 182 deficiencies at MACLAY HEALTHCARE CENTER during 2022 to 2025. These included: 6 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 6 that caused actual resident harm, 169 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Maclay Healthcare Center?
MACLAY HEALTHCARE 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 SERRANO GROUP, a chain that manages multiple nursing homes. With 141 certified beds and approximately 123 residents (about 87% occupancy), it is a mid-sized facility located in SYLMAR, California.
How Does Maclay Healthcare Center Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, MACLAY HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (41%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Maclay Healthcare Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.
Is Maclay Healthcare Center Safe?
Based on CMS inspection data, MACLAY HEALTHCARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 6 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Maclay Healthcare Center Stick Around?
MACLAY HEALTHCARE CENTER has a staff turnover rate of 41%, 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 Maclay Healthcare Center Ever Fined?
MACLAY HEALTHCARE CENTER has been fined $311,888 across 6 penalty actions. This is 8.6x the California average of $36,198. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Maclay Healthcare Center on Any Federal Watch List?
MACLAY HEALTHCARE CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.