GRAND VALLEY HEALTH CARE CENTER
For profit - Corporation
99 Beds
THE MANDELBAUM FAMILY
Data: November 2025
Trust Grade
15/100
#812 of 1155 in CA
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Grand Valley Health Care Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided at this facility. Ranking #812 out of 1155 in California places it in the bottom half of nursing homes, and #188 out of 369 in Los Angeles County suggests that there are better local options available. While the facility's performance is improving, with issues decreasing from 23 in 2024 to 11 in 2025, it still reported serious incidents of physical abuse between residents, leading to injuries that required medical attention. Staffing is average with a turnover rate of 38%, and while RN coverage is also average, the facility has incurred $63,190 in fines, which is higher than 84% of California facilities, indicating ongoing compliance problems. Families should weigh these serious weaknesses against the facility's strengths, such as some good quality measures, before making a decision.
- Trust Score
- F
- In California
- #812/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 38% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- $63,190 in fines. Lower than most California facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 73 deficiencies on record. Higher than average. Multiple issues found across inspections.
15/100
Bottom 30%
Review needed
23 → 11 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 23 issues
2025: 11 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (38%)
10 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below California average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 38%
Near California avg (46%)
Typical for the industry
Federal Fines: $63,190
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: THE MANDELBAUM FAMILY
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 73 deficiencies on record
2 actual harm
Aug 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was treated with ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect by not honoring Resident 1's request that Certified Nursing Assistant (CNA) 1, whom Resident 1 reported as being rough during care, not provide care to Resident 1 upon readmission to the facility.During a review of Resident 1's admission record, the admission Record indicated the facility admitted Resident 1 on 7/8/2025 and readmitted on [DATE] with diagnoses including fracture of the left femur (break of the long bone in the leg), osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), morbid obesity (severely overweight), and generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday events).During a review of Resident 1's History and Physical (H&P) dated 7/22/2025, the H&P indicated Resident 1 has decision-making capacity.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 7/27/2025, the MDS indicated Resident 1's cognition (ability to think and make decisions) was intact. The MDS further indicated that Resident 1 required set up assist with eating and personal hygiene and dependent on staff for toileting, showering, and lower and upper body dressing. During an interview on 8/22/2025 at 12:40 p.m. with Resident 1, Resident 1 stated that upon readmission to the facility, Resident 1 spoke with the facility case manager (CM) and requested that CNA 1 not to be in her presence or provide care for Resident 1. Resident 1 stated that the CM acknowledged the request and stated that CNA 1 would not be providing care for Resident 1 or be in her presence. Resident 1 stated that a few days following readmission to the facility CNA 1 was assigned to provide care to Resident 1's roommate and that CNA 1 did come into Resident 1's room and she felt uncomfortable with CNA 1 being in the room. Resident 1 stated that Resident 1 did inform the staff at the facility and CNA 1 was removed from that assignment.During an interview on 8/22/2025 at 2:40 p.m. with CNA 1, CNA 1 stated that on 7/25/2025 CNA 1 worked overtime on the 3 p.m. to 11p.m. shift and CNA 1 was assigned to Resident 1's room. CNA 1 stated that CNA 1 informed the assistant director of staff development (ADSD) that CNA 1 was not allowed to work with Resident 1. The ADSD then informed CNA 1, that CNA 1 will be assigned to the roommate of Resident 1. CNA 1 stated that she did enter Resident 1's room and informed Resident 1 that CNA 1 would be taking care of Resident 1's roommate. CNA 1 stated that Resident 1 did not say anything. CNA 1 further stated that during the shift on 7/25/2025 the call light (a communication device that allows residents to alert caregivers when they need assistance) in Resident 1's room did turn on and CNA 1 went to answer the call light and the call light was for Resident 1 who was requesting ice water. CNA 1 stated that she assisted Resident 1 by providing ice water.During an interview on 8/22/2025 at 3:15 p.m. with ADSD, ADSD stated that on 7/25/2025 ADSD made the assignment sheet for the 3 p.m. to 11 p.m. and originally assigned CNA 1 to Resident 1 but was informed that CNA 1 was not allowed to work with Resident 1. ADSD stated that ADSD changed the assignment and removed CNA 1 from Resident 1's room around 3 p.m.During an interview on 8/22/2025 at 3:25 p.m. with the CM, the CM stated that prior to Resident 1's readmission to the facility on 7/21/2025, the CM was informed that Resident 1 did not want CNA 1 to provide care for Resident 1 or be around CNA 1.During an interview on 8/22/2025 at 4:20 p.m. with the Director of Nursing (DON), the DON stated that Resident 1 had requested CNA 1 not provide care for Resident 1 upon readmission to the facility. The DON confirmed that CNA 1 entered Resident 1's room and spoke to Resident 1. The DON stated that CNA 1 should not have spoken to Resident 1 or entered the room or had any contact with Resident 1. The DON stated that the presence of CNA 1 in Resident 1's room has the potential to cause increased anxiety, fear and feelings of discomfort.During a review of the facility policy and procedure (P&P) titled Resident's Right to Dignity and Privacy dated 8/15/2024, indicated it is the policy of the facility that each resident shall be cared for in a manner that promotes dignity, respect and individuality and provides for resident privacy. The facility will protect and promote the rights of the resident.Resident shall be treated with dignity and respect at all times.to be encouraged and assisted to exercise rights as a resident and as a citizen, and voice grievances without interference, coercion, fear of discrimination or reprisal and to be supported by the facility in the exercise of his or her rights and to recommend changes in policies and services to facility staff and/or outside representatives of the resident's choice and to have the facility respond to those grievances.
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
Deficiency F0627
(Tag F0627)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was actively inv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was actively involved in their discharge planning and had a safe discharge to a lower level of care.This deficient practice resulted in Resident 1 having to be admitted to the general acute care hospital (GACH) within 24 hours of discharge to a lower level of care and had the potential for decreased quality of care, decreased quality of life, and continuity of care.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/13/2025 with diagnosis including chronic venous hypertension with ulcer (long-lasting skin sore on the leg, caused by poor blood flow in the veins) of left lower extremity and methicillin resistant staphylococcus aureus infection (a bacterial infection caused by a type of bacteria that has become resistant to many of the antibiotics used to treat ordinary infections).During a review of Resident 1's History & Physical (H&P) dated 6/14/2025, the H&P indicated the resident does have capacity to make decisions.During a review of Resident 1's Social Work Progress Note dated 7/24/2025, the Social Work Progress Note indicated Resident 1 met with referral agency. Referral agency spoke to Resident 1 and informed Resident 1 that the referral agency will find the right placement for Resident 1. Resident 1 agreed.During a review of Resident 1's Social Work Progress Note dated 7/31/2025, the Social Work Progress Note indicated that the Social Services Director (SSD) received a call from the referral agency and stated that the referral agency has a facility for Resident 1 to be placed and provided the SSD with the address of the board and care (licensed residential settings that provide housing, meals, and personal care assistance to seniors who need help with daily living activities but don't require 24-hour skilled nursing care) and contact information. The SSD placed a call to the accepting board and care and stated that the board and care has accepted Resident 1 and has a bed available for Resident 1. The SSD requested the board and care to come and evaluate Resident 1, however the board and care stated that the board and care has all the information and was not necessary. The document continued to indicate that the SSD met with Resident 1 and Resident 1 was made aware the board and care has an available bed.During a review of Resident 1's Social Work Progress Note dated 7/31/2025, the Social Work Progress Note indicated Resident agreed to be discharged on 8/2/2025.During a review of Resident 1's physician order dated 8/1/2025 timed at 3:56 p.m., the physician order indicated discharge resident to resident to board and care with home health.During a review of Resident 1's Nursing Progress Note dated 8/2/2025, the Nursing Progress Note indicated that Resident 1 left (discharged ) stable.During a review of Resident 1's Social Work Progress Note dated 8/4/2025, the Social Work Progress Note indicated that the SSD was informed by admissions that Resident 1 was sent to the hospital from the board and care.During a review of Resident 1's GACH Physician Progress Notes dated 8/5/2025, the GACH Physician Progress Notes indicated Resident 1 was admitted on [DATE] and was diagnosed with a urinary tract infection (UTI- an infection in the bladder/urinary tract). Resident 1's care plan indicated intravenous (IV- fluids given directly into the blood stream) ceftriaxone (antibiotic used to treat bacterial infections in many different parts of the body) 1,000 milligrams (mg- unit of measurement) daily, and infectious disease follow-up.During an interview on 8/7/2025 at 4:22 p.m., with the SSD, the SSD stated that the discharge process starts on admission. The SSD stated that the SSD will discuss discharge planning with residents and/or residents' representatives in regards to discharge planning and the SSD provides information and choices on various types of lower level care facilities if requested. The SSD stated that Resident 1's discharge plan was to go to a lower level of care such as an assisted living facility or a board and care. The SSD stated that she was able to find a referral agency to assist Resident 1in finding placement. The SSD stated that the referral agency was able to find placement for Resident 1. The SSD continued to state that the SSD provided the board and care address to Resident 1. When asked if Resident 1 was given a choice in what board and care Resident 1 would be discharged to, the SSD stated that Resident 1 was not given a choice. When asked if Resident 1 was offered to see and tour the prospective board and care that Resident 1 would be discharged to, the SSD stated that the SSD did not ask Resident 1 if he (Resident 1) wanted to see and/or tour the prospective board and care. The SSD further stated that the SSD spoke to the referral agency that found the board and care for Resident 1 and received the address. The SSD stated that the SSD then provided the address of the board and care to Resident 1 and no additional orientation was provided to Resident 1 prior to Resident 1's discharge. When asked if the SSD would move into a facility without seeing the location first, the SSD stated that she would not move to a place that she had not seen before.During a follow-up interview on 8/7/2025 at 4:45 p.m., with the SSD, the SSD stated that Resident 1 was not an active participant in his discharge planning. The SSD continued to state that Resident 1 was not safely discharged to the board and care because he wa transferred to the GACH the same day Resident 1 was discharged on 8/2/2025.During an interview on 8/8/2025 at 10:34 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that Resident 1's discharge was an unsafe discharge because the SSD should have explained and documented the discharge process thoroughly, provided Resident 1 with choices, and Resident 1 should not have been admitted to the hospital less than 24 hours of being discharge to a lower level of care. During an interview on 8/8/2025 at 1:30 p.m., with Resident 1, Resident 1 stated that he was transferred to an unknown location on 8/2/2025. Resident 1 stated that the SSD provided him (Resident 1) with an address and stated that Resident 1 will be discharged to the address that was given on 8/2/2025. Resident 1 stated he did not have a choice but to follow what the SSD said. Resident 1 stated that every time Resident 1 wanted to talk to the SSD, the SSD stated that she was very busy and did not explain fully what was going on with the discharge process. Resident 1 continued to state that when he arrived at the board and care, it was a house with a white picket fence and three male individuals had to carry his wheelchair up the stairs because there was no ramp for his wheelchair to get to the front door of the house. Resident 1 stated that he was in the house (board and care) for no more than one (1) hour when a male individual informed Resident 1 that he will be transferring Resident 1 to another place. The three male individuals carried Resident 1 and his wheelchair back down the stairs to a private vehicle. Resident 1 stated that the house was a very strange place. Resident 1 continued to state that he did not feel safe and stated that he was dumped in the house (board and care). During a review of the facility's policy and procedure (P&P) titled, DischargeProcess, review date 8/15/2024, the policy indicated the discharge planning process must focus on discharge planning goals and should prepare a resident to be an active partner is their post-discharge care and the transition process in an attempt to reduce factors leading to preventable readmission.The facility will provide and document sufficient preparation and orientation to residents for transfer or discharge to ensure a safe and orderly transfer or discharge from the facility in a form and manner that the resident can understand. The policy indicated Preparation for discharge: 1. The resident should be consulted regarding the discharge.2. Discharge can be frightening for the resident.4. If discharging the resident to another long-term care facility tell the resident:a. Where the new facility is located.b. How large the facility is, what services it offers, what it looks like, etc.c. Any information you can about the facility. d. Who will be providing the resident's care.e. That his or her family and visitors will be informed of the discharge and where the resident will be living.f. Why the discharge is 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 F0628
(Tag F0628)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' Notice of Proposed Transfer and Discharge were pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' Notice of Proposed Transfer and Discharge were provided to the resident and/or resident representative at least 30 days prior to discharge or as soon as practicable for three of three sampled residents (Resident 1, Resident 2, and Resident 3).This deficient practice placed the residents at increased risk of an inappropriate discharge and denied the residents the right to file an appeal to the appropriate agency within 10 days of being notified of a proposed transfer and discharge.a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/13/2025 with diagnosis including chronic venous hypertension with ulcer (long-lasting skin sore on the leg, caused by poor blood flow in the veins) of left lower extremity and methicillin resistant staphylococcus aureus infection (a bacterial infection caused by a type of bacteria that has become resistant to many of the antibiotics used to treat ordinary infections).During a review of Resident 1's History & Physical (H&P) dated 6/14/2025, the H&P indicated the resident does have capacity to make decisions.During a review of Resident 1's Social Work Progress Note dated 7/31/2025, the Social Work Progress Note indicated Resident agreed to be discharged on 8/2/2025.During a review of Resident 1's physician order dated 8/1/2025 timed at 3:56 p.m., the physician order indicated discharge resident to resident to board and care (licensed residential settings that provide housing, meals, and personal care assistance to seniors who need help with daily living activities but don't require 24-hour skilled nursing care) with home health.During a review of Resident 1's document titled, Notice of Transfer/Discharge, dated 8/2/2025, the Notice of Transfer/Discharge document indicated the notification with given to Resident 1 on 8/2/2025.During a concurrent interview and record review on 8/8/2025 at 10:00 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 1's Social Work Progress Note dated 7/31/2025. The ADON stated that once the facility is aware of a resident's discharge, licensed nurses and social services should give the resident and/or resident responsible party the notice of transfer and discharge. The ADON stated that Resident 1 should have been given the Notice of Transfer/discharge on [DATE] when social services was aware of the upcoming discharge to the board and care. The ADON stated that it is important to give residents' and/or residents' representative the Notice of Transfer/Discharge to inform the resident and/or resident representative that the resident will be transferred or discharged . The DON stated it will give the residents and/or residents' representative the opportunity to appeal if they do not agree with the discharge. The ADON further stated that Resident 1 was discharged to the board and care on 8/2/2025.b. During a review of Resident 2's admission Record, the admission Record indicated the facility readmitted Resident 2 on 7/13/2025 with diagnosis including urinary tract infection (an infection in the bladder/urinary tract), cellulitis (a skin infection that causes swelling and redness) of the right lower limb, and cellulitis of the left lower limb.During a review of Resident 2's H&P dated 7/15/2025, the H&P indicated the resident does have capacity to make decisions.During a review of Resident 2's care plan (a document that summarizes a resident's needs, goals, and care/treatment) for discharge planning dated 7/14/2025, the care plan indicated Resident 2 plans to return to Assisted Living Facility (housing facility for one who chooses not to live independently) after rehabilitation services have been completed and her health improves.During a review of Resident 2's physician order dated 8/1/2025 timed at 4:17 p.m., the physician order indicated to discharge resident back to ALF on 8/2/2025.During a review of Resident 2's document titled, Notice of Proposed Transfer /Discharge, dated 8/2/2025, the Notice of Transfer/Discharge document indicated the notification was given to Resident 2 on 8/2/2025.During a concurrent interview and record review on 8/8/2025 at 11:06 a.m., with the Case Manager (CM), reviewed Resident 2's Notice of Transfer/discharge date d 8/2/2025 and Resident 2's Notice of Medicare Non-Coverage (NOMNC- written notice designed to inform Medicare members that their covered care is ending) dated 7/30/2025. The CM stated that Resident 2 was admitted for a short-term stay for rehabilitation. The CM stated that the NOMNC is given to the resident and/or resident's representative 72 hours before the last insurance cover date, in which the resident will be discharged from insurance coverage. The CM stated that Resident 2's Notice of Transfer/Discharge was given to Resident 2 on 8/2/2025, the day of Resident 2's discharge. The CM continued to state that the Notice of Transfer/Discharge document is given on the day of discharge and is provided to the residents and/or resident's representative on the day of discharge along with other discharge documents. The CM stated that the Notice of Transfer/Discharge should have been given to Resident 2 on 7/30/2025 when the NOMNC was given.c. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 7/14/2025 with diagnosis including pneumonia (an infection/inflammation in the lungs).During a review of Resident 3's H&P dated 7/15/2025, the H&P indicated Resident 3 has the capacity to make decisions.During a review of Resident 3's care plan for discharge planning dated 7/15/2025, the care plan indicated Resident 3 plans to return to ALF after rehabilitation services have been completed and his health improves.During a review of Resident 3's physician order dated 7/28/2025 timed at 1:36 p.m., the physician order indicated to discharge Resident 3 to ALF on 7/28/2025.During a review of Resident 3's document titled, Notice of Proposed Transfer /Discharge, dated 7/28/2025, the Notice of Transfer/Discharge document indicated the notification with given to Resident 3 on 7/28/2025.During a concurrent interview and record review on 8/8/2025 at 11:35 a.m., with the CM, reviewed Resident 3's Notice of Transfer/discharge date d 7/28/2025 and Resident 3's NOMNC dated 7/25/2025. The CM stated that Resident 3 was admitted for a short-term stay for rehabilitation. The CM stated that Resident 3's Notice of Transfer/Discharge was given to Resident 3's on 7/28/2025, the day of Resident 3's discharge. The CM continued to state that the Notice of Transfer/Discharge document is given on the day of discharge. The CM stated that the Notice of Transfer/Discharge should have been given to Resident 3 on 7/25/2025 when the NOMNC was given so that Resident 3 and his family have time to appeal Resident 3's stay if they chose to. During a review of the facility's policy and procedure (P&P) titled, Discharge Process, review date 8/15/2024, the P&P indicated the notice of transfer or discharge required must be made by the facility at least 30 days prior to the transfer or discharge or as soon as practicable.
Aug 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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident's low air loss mattress (a specializ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident's low air loss mattress (a specialized mattress that alternates pressure to prevent skin breakdown) was in the correct setting for one (Resident 1) of three sampled residents.This deficient practice had the potential to place the resident at increased risk for discomfort and development of pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with the most recent admission on [DATE] with diagnoses including urinary tract infection (UTI-an infection in the blader/urinary tract), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), morbid obesity (severely over weight), cerebral infarction (a condition where part of the brain dies due to lack of blood supply), and paraplegia (loss of movement and/or sensation, to some degree, of the legs).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 6/19/2025, the MDS indicated Resident 1's condition (ability to think and make decisions) was intact. The MDS further indicated that Resident 1 required set up assistance from staff with eating, and oral hygiene. The MDS indicated Resident 1 was dependent on staff for toileting hygiene, showering, lower body dressing and putting on/taking of footwear.During a review of Resident 1's Physician Order dated 7/18/2025, the Physician Order indicated for Resident 1 to have a low air loss mattress for skin management.During a concurrent interview and observation on 7/31/2025 at 1:15 p.m. with Licensed Vocational Nurse (LVN) 1, observed Resident 1's low air loss mattress was set for a weight between 600 and 1000 pounds (lbs.-unit of weight). LVN 1 confirmed that the low air loss mattress was set between 600 and 1000 lbs. LVN 1 confirmed that Resident 1's posted weight was 246 lbs. and that the low air loss mattress setting was out of range for Resident 1. LVN 1 stated that the low air loss mattress setting should be lower than 250 lbs.During an interview on 8/1/2025 at 1:30 p.m. with the Director of Nursing (DON), the DON stated that Resident 1's low air loss mattress should be in the correct setting. The DON confirmed that Resident 1's low air loss mattress was not in the correct setting and should be set according the resident's current weight. The DON stated that there is an increased risk of skin breakdown which could lead to pressure ulcer if Resident 1's low air loss is not in the correct setting.During a review of the facility's policy and procedure (P&P) titled Prevention of Pressure Injures also known as Pressure Sores dated 8/15/2024, the P&P indicated that the purpose of this procedure is to provide information regarding identification of pressure injury also known as pressure sore risk factors an interventions for specific factors.Pressure injures.are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or decrease of circulation (blood flow) to an area with subsequent destruction of tissue.interventions and preventive measures include to use a special mattress that contains foam, air, gel, or water, as indicated.
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
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to ensure one of three sampled residents (Resident 2) received care and servi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to ensure one of three sampled residents (Resident 2) received care and services in accordance with professional standards of practice by failing to administer Resident 2's Norco (a medication used to relieve severe pain) as prescribed by the physician. This deficient practice had the potential for Resident 2 to experience untreated pain.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 6/2/2022 and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the body due to an underlying illness or organ dysfunction), sepsis (a serious condition in which the body responds improperly to an infection), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and chronic pain syndrome (a condition where pain persists for more than three to six months, beyond the expected healing time for an injury or illness). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 6/19/2025, the MDS indicated Resident 2 had intact cognition (the process of acquiring knowledge and understanding through thought, experience, and senses). The MDS further indicated that Resident 2 required set-up or clean up assistance with eating, and oral hygiene, partial or moderate assistance with personal hygiene, and was dependent on staff with toileting hygiene. During a review of Resident 2's Order Summary Report dated 2/26/2025, the Order Summary Report indicated an order for Norco Oral Tablet 5-325 milligrams (mg- unit of measurement), give one (1) tablet orally every six (6) hours as needed for severe pain (pain rated at seven to 10 on a pain scale from zero [0] to 10, where 10 is the worst possible pain). During a review of Resident 2's Situation, Background, Assessment and Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 6/21/2025, the SBAR indicated Resident 2 had nine (9) out of 10 pain in the perineal area (the area between the anus and genitals). During a review of Resident 2's Care Plan for pain dated 7/7/2025, the Care Plan indicated under interventions to administer medications as ordered by the physician. During a review of Resident 2's Medication Administration Record (MAR - a legal record of all medications and treatments administered to a resident) for 6/2025, the MAR indicated to give Norco 5-325 mg one tablet orally every six hours as needed for severe pain (seven to 10 out of 10 pain). There was no entry or documented evidence in Resident 2's MAR indicating Norco 5-325 mg one tablet was given on 6/21/2025. During a concurrent interview and record review on 7/16/2025 at 2:00 p.m., with the Case Manager (CM), the CM reviewed Resident 2's SBAR Communication Form dated 6/21/2025 and MAR for 6/2025. The CM stated that Resident 2 had a change in condition (significant alteration in a person's physical, mental, or functional state) on 6/21/2025 for tachycardia (a medical condition characterized by an abnormally fast heart rate) and fever. The CM stated that Resident 2's pain level was evaluated and stated that Resident 2's pain level was documented to be nine out of 10 in the perineal area. The CM further stated that Resident 2 was not administered PRN (as needed) pain medication on 6/21/2025. During an interview on 7/16/2025 at 2:39 p.m., with Registered Nurse 2 (RN 2), RN 2 stated that on 6/21/2025 the charge nurse (Licensed Vocational Nurse 1 [LVN 1] assigned to Resident 2 reported to RN 2 on 6/21/2025 that Resident 2 had tachycardia and fever. RN 2 stated that she (RN 2) then went to Resident 2's room to assess Resident 2. RN 2 stated that during the assessment, Resident 2 complained of nine out of 10 pain in her perineal pain. When asked if Resident 2 was offered pain medication as prescribed by the physician or if pain medication was administered to address Resident 2's nine out of 10 pain, RN 2 stated that pain medication was not administered to Resident 2. RN 2 stated that Resident 2 should have been administered pain medication because of Resident 2's complaint of pain. When asked why Resident 2 was not administered pain medication, RN 2 did not answer. RN 2 further stated that Resident 2 should have been administered pain medication for her nine out of 10 pain because Resident 2 had PRN pain medication ordered and by administering Resident 2's PRN pain medication it would have helped address and relieve the pain. During a review of the facility's policy and procedure (P&P) titled, Pain Management Protocol, last reviewed by the facility on 8/15/2024, the policy indicated pain management may consist of continuous narcotic infusing, routine medication, PRN medication or a combination of both medication and PRN medication for breakthrough pain. During a review of the facility's P&P titled, Medication Administration-General Guidelines, last reviewed by the facility on 8/15/2024, the policy indicated medications are administered as prescribed in accordance with good nursing principles and practices and only persons legally authored to do so. Medications are administered in accordance with written orders of the attending physician. During a review of the facility's P&P titled, Quality of Care, Routine Resident Monitoring and Scope of Services, last reviewed by the facility on 8/15/2024, the policy indicated it is the policy of the facility that each resident receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being consistent with the residents comprehensive assessment and plan of care.
Jun 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure clinical records for one of four sampled residents (Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure clinical records for one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards by failing to accurately document the administration of Resident 1's Oxycodone Hydrocholoride (a medication used to treat moderate to severe pain) on the Medication Administration Record (MAR- a report that serves as a legal record of the medications administered to a resident).
This deficient practice placed Resident 1 at risk for medication errors, delayed pain relief and the potential for diversion (refers to redirection of prescription drugs from their intended use or disposal to unauthorized purposes) of a narcotic (a substance that dulled the senses and relieved pain) medication.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture (broken bone) of lower end of right femur (thigh bone), type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD- irreversible kidney failure) and muscle weakness.
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/18/2025, the MDS indicated Resident 1's cognition (ability to think and make decisions) was intact. The MDS further indicated that Resident 1 required set-up assistance from staff with eating, oral hygiene and personal hygiene. The MDS indicated Resident 1 required maximum assistance from staff with toileting hygiene, showering, lower body dressing and putting on/taking off footwear.
During a review of Resident 1's History and Physical (H&P) dated 6/13/2025, the H&P indicated Resident 1 has decision-making capacity.
During a review of Resident 1's Physician Order Summary dated 6/12/2025, the Physician Order Summary indicated to give Oxycodone Hydrochloride oral tablet 10 milligrams (mg- unit of measurement), one tablet by mouth every four hours as needed for moderate to severe pain.
During a review of Resident 1's Controlled Drug Record (refers to a detailed log or documentation system used to track the receipt, distribution, administration and disposal of controlled substances [refers to a medication or drug that is regulated by the government due to its potential for abuse or addiction]) dated 6/13/2025, the Controlled Drug Record indicated that Oxycodone Hydrochloride was signed out for administration to Resident 1 by Licensed Vocational Nurse (LVN) 1 on 6/13/2025 at 9:30 p.m. and LVN 2 on 6/14/2025 at 11:00 a.m.
During a review of Resident 1's MAR, dated 6/2025, the MAR did not indicate Oxycodone Hydrocholoride was administered for the doses signed out in the Controlled Drug Record on 6/13/2025 at 9:30 p.m. and 6/14/2025 at 11:00 a.m.
During an interview on 6/27/2025 at 2:30 p.m., with the Director of Nursing (DON), the DON stated that when nursing staff administer medication to a resident, it should be documented on the MAR to reflect the administration of the medication and align with the corresponding entries in the Controlled Drug Record. The DON stated that the Oxycodone Hydrochloride signed out for Resident 1 on 6/13/2025 at 9:30 p.m. and 6/14/2025 at 11:00 a.m. should have been documented on Resident 1's MAR to indicate that it was administered.
During a review of the facility's policy and procedure (P&P) titled Medication Administration-General Guidelines dated 8/15/2024, the P&P indicated medications are administered only by licensed nursing, medical, pharmacy or other personal authorized by state laws and regulations to administer medication. Medications are administered in accordance with written orders of the attending physician .The individual who administers the medication dose records the administration on the residents MAR directly after mediation is given. At the end of reach medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented.
May 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency 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 necessary assistance wi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were provided necessary assistance with activities of daily living, specifically with mobility and getting out of bed for two of two sampled residents (Resident 3 and Resident 4).
This deficient practice resulted in residents remaining in bed for prolonged periods and potentially compromise residents ' dignity, preferences and functional well-being.
Findings:
a. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/17/2025 and readmitted Resident 3 on 3/30/2025 with diagnoses that included traumatic subdural hemorrhage (bleeding in the area between the brain and the skull usually caused by a head injury) without loss of consciousness (state of being awake and aware of one ' s surroundings), pneumonia (lung infection) and epilepsy (a neurological disorder characterized by recurring seizure [a sudden burst of electrical activity in the brain causing changes in behavior, movement, feelings and level of consciousness]).
During a review of Resident 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated 4/5/2025, the MDS indicated Resident 3 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was moderately impaired. The MDS indicated Resident 3 was dependent (helper does all of the effort and resident does none of the effort to complete activity) on staff with oral hygiene, toileting hygiene, dressing, personal hygiene and mobility (movement).
During an observation on 5/19/2025 at 9:30 a.m., in Resident 3 ' s room, observed Resident 3 in bed with call light within reach and observed gastrostomy (g-tube- a medical device that ' s surgically placed through the abdominal wall and into the stomach used to provide direct access for supplemental feeding, hydration or medication) feeding on.
During an observation on 5/19/2025 at 10:50 a.m., in Resident 3 ' s room, observed Resident 3 in bed with call light within reach and observed g-tube feeding off.
During an observation on 5/19/2025 at 12:52 p.m., in Resident 3 ' s room, observed Resident 3 in bed with call light within reach and observed g-tube feeding off.
During an interview on 5/19/2025 at 1:24 p.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated that she (CNA 3) is assigned to Resident 3 today (5/19/2025). CNA 3 stated that she (CNA 3) provided Resident 3 with morning care (care given in the morning to prepare the resident for the day). When asked if Resident 3 was assisted and taken out of bed, CNA 3 stated that she (CNA 3) did not take Resident 3 out of bed because Resident 3 has a g-tube. When asked if Resident 3 was offered to get out of bed, CNA 3 stated that she (CNA 3) did not offer to get Resident 3 out of bed because she forgot. When asked about the importance of taking residents out of bed, CNA 3 stated that it important to get residents out of bed because it will help residents not develop bed sores (skin injury caused by prolonged pressure on the body, particularly over bony areas), to help with their (residents) mobility, and to help with their (residents) entertainment.
During an observation on 5/19/2025 at 1:45 p.m., in Resident 3 ' s room, observed Resident 3 in bed with call light within reach and observed g-tube feeding off.
During an interview on 5/19/2025 at 2:00 p.m., with the Director of Staff Development (DSD), the DSD stated that getting residents out of bed is part of residents ' morning care. The DSD stated that the facility would like all residents to be out of bed by 11:00 a.m., each day. The DSD stated residents do not require a physician ' s order to get out of bed. When asked why Resident 3 was kept in bed, the DSD stated that Resident 3 is on g-tube feeding and the facility would rather keep Resident 3 in bed, depending on feeding times. The DSD stated that Resident 3 ' s g-tube feeding is turned on at 12:00 p.m. and turned off at 8:00 a.m.
b. During a review of Resident 4 ' s admission Record, the admission Record indicated the facility originally admitted Resident 4 on 12/15/2023 and readmitted Resident 4 on 4/8/2025 with diagnoses that included pneumonia, chronic obstructive pulmonary disease (COPD - a lung disease causing restricted air flow and breathing problems) and low back pain.
During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated Resident 4 ' s cognition was intact. The MDS indicated Resident 4 required partial or moderate assistance from staff with mobility (movement) such as sit to stand and chair/bed to chair transfer.
During an observation on 5/19/2025 at 9:32 a.m., in Resident 4 ' s room, observed Resident 4 in bed with call light within reach.
During an observation on 5/19/2025 at 11:52 a.m., in Resident 4 ' s room, observed Resident 4 in bed, watching tv, with call light within reach.
During an observation on 5/19/2025 at 12:55 p.m., in Resident 4 ' s room, observed Resident 4 in bed being assisted by a facility staff with lunch.
During a concurrent observation and interview on 5/19/2025 at 1:05 p.m., in Resident 4 ' s room, observed Resident 4 in bed, watching tv, with call light within reach. Resident 4 stated that the physical therapist (a health professional trained to evaluate and treat people who have conditions or injuries that limit their ability to move and do physical activities) gets her up, out of bed and assists her with walking, usually in the afternoon at around 3:00 p.m. When asked if nursing staff gets Resident 4 up, out of bed, Resident 4 stated that nursing staff do not get her out of bed. When asked if nursing staff offer Resident 4 to get out of bed and on to a chair, Resident 4 stated that nursing staff have not offered to get her out of bed and have not offered for her to sit on a chair. Resident 4 continued to state that she (Resident 4) was not aware that nursing staff was allowed to get her out of bed.
During a follow up interview on 5/19/2025 at 2:45 p.m., with the DSD, the DSD stated that assisting residents to get out of bed is a standard part of the CNA ' s daily responsibilities and is expected to be performed for all residents. The DSD stated CNAs should be offering each resident if he/she wishes to get out of bed. If residents refuse for any reason, CNAs are to report to the charge nurse. The DSD continued to state that getting residents out of bed affects residents ' quality of life because residents staying in their rooms and not given an opportunity to get out of bed can lead to residents ' decline in their psychosocial well-being. The DSD further stated that that DSD should be supervising the CNAs accordingly to ensure that residents are getting out of bed and being offered to get out of bed.
During an interview on 5/20/2025 at 11:49 a.m., with the Administrator (ADM), the ADM stated that all residents should be offered to get out of bed as part of the residents' activities of daily living.
During a review of the facility ' s policy and procedure titled Activities of Daily Living, and Scope of Services, last reviewed in 8/15/2024, indicated it is the policy that each resident receives, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being consistent with the resident ' s comprehensive assessment and plan of care. This will include that nursing staff conduct routine resident monitoring to ensure resident safety and well-being. Staff will ensure that Activities of Daily Living are monitored, assisted with, and provided for those residents who are unable to perform Activities of Daily Living. Under procedure: Ensure that the following ADL functions are monitored, supervised, assisted with and or provided to the Resident population that the facility is servicing to include but not limited to g. Transferring bed/chair.
During a review of the facility ' s policy and procedure titled Quality of Care, Routine Resident Monitoring and Scope of Services, last reviewed in 8/15/2024, indicated it is the policy that each resident receives, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being consistent with the resident ' s comprehensive assessment and plan of care. This will include that nursing staff conduct routine resident monitoring to ensure resident safety and well-being. The facility to provide hygiene, bathing, dressing, grooming and oral care, mobility-transfer and ambulation including walking, toileting, dining-eating, including meals and snacks, and communication to residents assessed to require these services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide oral care for one of three sampled residents (Resident 3).
This deficient practice resulted in Resident 3 not being ...
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Based on observation, interview, and record review, the facility failed to provide oral care for one of three sampled residents (Resident 3).
This deficient practice resulted in Resident 3 not being provided with oral care on 5/16/2025 which could lead to potential negative outcomes such as development of oral health issues (discomfort and pain) including tooth decay or gum disease.
Findings:
During a review of Resident 3 ' s admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/17/2025 and readmitted Resident 3 on 3/30/2025 with diagnoses that included traumatic subdural hemorrhage (bleeding in the area between the brain and the skull usually caused by a head injury) without loss of consciousness (state of being awake and aware of one ' s surroundings), pneumonia (lung infection) and epilepsy (a neurological disorder characterized by recurring seizure [a sudden burst of electrical activity in the brain causing changes in behavior, movement, feelings and level of consciousness]).
During a review of Resident 3 ' s Minimum Data Set (MDS- a resident assessment tool) dated 4/5/2025, the MDS indicated Resident 3 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was moderately impaired. The MDS indicated Resident 3 was dependent (helper does all of the effort and resident does none of the effort to complete activity) on staff with oral hygiene, toileting hygiene, dressing, personal hygiene and mobility (movement).
During a review of Resident 3 ' s Care Plan for Self-Care and Functional Mobility dated 4/7/2025, the Care Plan indicated that Resident 4 had impaired self-care abilities and functional mobility and was dependent on staff for oral hygiene. The interventions included to assist the resident with personal hygiene and provide oral care.
During an observation on 5/16/2025 at 11:35 a.m., in Resident 3 ' s room, observed Resident 3 in bed with dry, cracked lips.
During a concurrent observation and interview on 5/16/2025 at 12:10 p.m., with Certified Nursing Assistant 1 (CNA 1), in Resident 3 ' s room, observed Resident 3 in bed. CNA 1 stated that she (CNA 1) was assigned to Resident 3 for the day (5/16/2025) but Resident 3 is not part of CNA 1 ' s regular assignment. CNA 1 stated CNA 1 provided Resident 3 oral care. When CNA 1 was asked to describe Resident 3 ' s mouth, CNA 1 stated Resident 3 ' s lips are dry. When CNA 1 was asked to describe Resident 3 ' s tongue, CNA 1 stated that Resident 3 ' s tongue is not clean, with a buildup of thick white and yellow stuff (coating) on Resident 3 ' s tongue. CNA 1 continued to state that Resident 3 ' s tongue has been like that for a long time. CNA 1 stated that Resident 3 ' s tongue was not normal and reported to Licensed Vocational Nurse 1 (LVN 1) on 5/16/2025 at around 10:00 a.m.
During an interview on 5/16/2025 at 12:20 p.m., with LVN 1, LVN 1 stated that LVN 1 was not made aware of concerns related to Resident 3 ' s tongue until this morning (5/16/2025) at around 10:00 a.m. LVN 1 continued to state that LVN 1 was made aware of the condition of Resident 3 ' s tongue at 12:15 p.m., after the surveyor spoke to CNA 1.
During a follow up interview on 5/16/2025 at 12:25 p.m., with CNA 1, CNA 1 stated that CNA 1 did not provide oral care to Resident 3. CNA 1 stated that she (CNA 1) informed LVN 1 of the condition of Resident 3 ' s tongue after being interviewed by the surveyor. CNA 1 stated that she (CNA 1) was about to provide Resident 3 with oral care but was not able to because Resident 3 started to scream. When asked why CNA 1 did not report to LVN 1, CNA 1 did not respond to the question and stated sorry.
During an interview on 5/16/2024 at 2:46 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that all residents, even residents who are on gastrostomy (g-tube- a medical device that ' s surgically placed through the abdominal wall and into the stomach used to provide direct access for supplemental feeding, hydration or medication) feeding should be provided oral care in the morning and before going to bed.
During an interview on 5/16/2025 at 3:17 p.m., with the Director of Staff Development (DSD), the DSD stated that the facility failed to provide proper oral care to Resident 3 and failed to report Resident 3 ' s tongue condition so that Resident 3 ' s tongue condition can be addressed right away. The DSD stated that CNA 1 should have provided oral care in the morning as part of Resident 3 ' s Activities of Daily Living (ADLs- routine tasks or activities [such as personal hygiene, bathing, dressing and toileting] a person performs daily to care for themselves) and if there were any issues or concerns such as refusals or experiencing discomfort, CNA 1 should have reported to LVN 1 so that that the issue or concern will be addressed timely.
During an interview on 5/20/2025 at 11:50 a.m., with the Administrator (ADM), the ADM stated that all residents should be provided quality care, and that oral care is to be provided to all residents.
During a review of the facility ' s policy and procedure titled Oral Care, last reviewed in 8/15/2024, indicated it is the policy of the facility that oral care should be done at least once each shift and more frequently as necessary to cleanse and freshen the resident ' s mouth and prevent complications, such as infections of the mouth.
During a review of the facility ' s policy and procedure titled Activities of Daily Living, and Scope of Services, last reviewed in 8/15/2024, indicated it is the policy of the facility that each resident receives, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being consistent with the resident ' s comprehensive assessment and plan of care. This will include that nursing staff conduct routine resident monitoring to ensure resident safety and well-being. Staff will ensure that Activities of Daily Living are monitored, assisted with, and provided for those residents who are unable to perform Activities of Daily Living. Under procedure: Ensure that the following ADL functions are monitored, supervised, assisted with and or provided to the Resident population that the facility is servicing to include but not limited to c. mouth care. The person conducting the routine check shall report promptly to the Nurse supervisor/Charge Nurse any change in the resident ' s condition and/or medical needs. If resident is unable to conduct activities of daily living, they are to be provided services to maintain good nutrition, grooming, and personal and oral hygiene.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement an effective bowel (tube-shaped organ in the abdomen that...
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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 an effective bowel (tube-shaped organ in the abdomen that completes the process of digestion) and bladder (a hollow organ that stores urine) retraining program (B&B retraining program - aim to establish or regain control over bowel and bladder function) for two of three sampled residents (Resident 1 and Resident 3) by not ensuring that the resident ' s bowel and bladder assessment was re-assessed in a timely manner.
This deficient practice had the potential to result in Resident 1 and Resident 3 not being accurately assessed as candidates for a B&B retraining program and may have limited their (Resident 1 and Resident 3) opportunity to regain bowel and bladder function.
Findings
a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 2/27/2025 with diagnoses that included osteoporosis (a bone disease that develops when the quality and structure of the bone changes) with current left femur fracture (broken thighbone), chronic kidney disease (long-term medical condition where your kidneys are not working well enough to filter blood, leading to a buildup of waste and fluid in the body) stage four (severe).
During a review of Resident 1 ' s History and Physical (H&P) dated 2/28/2025, the H&P indicated Resident 1 has decision making capacity.
During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 3/5/2025, the MDS indicated Resident 1 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required extensive assistance from staff with bed mobility, dressing, and personal hygiene. The MDS also indicated that Resident 1 required supervision or touching assistance with eating, oral hygiene, and personal hygiene and required substantial or maximal assistance with toileting hygiene.
During a review of Resident 1 ' s Bowel and Bladder assessment dated [DATE], the Bowel and Bladder Assessment indicated Resident 1 had functional incontinence (unable to get to toilet in time due to physical disability, external obstacles, or problems with thinking or communicating). The Bowel and Bladder Assessment indicated Resident 1 was occasionally incontinent (inability to control urination, less than seven episodes of incontinence) with bladder function and occasionally incontinent (inability to control bowel movements, one episode of incontinence) with bowel function. Further review of Resident 1 ' s Bowel and Bladder Assessment form indicated to complete an evaluation after 72 hours however the evaluation was not completed until 3/12/2025.
During a concurrent interview and record review on 5/19/2025 at 12:00 p.m., with Registered Nurse 1 (RN 1), Resident 1 ' s Bowel and Bladder assessment dated [DATE] was reviewed. RN 1 stated that Bowel and Bladder Assessments are done upon admission. RN 1 stated Resident 1 ' s Bowel and Bladder Assessment was not completed in a timely manner. RN 1 stated that licensed nurses are expected to re-evaluate the resident 72 hours after the initial Bowel and Bladder Assessment to determine if the resident is a candidate for B&B retraining program and to document their findings accordingly. The 72-hour evaluation section was completed on 3/12/2025, 10 days late. RN 1 stated that Resident 1 ' s Bowel and Bladder 72-hour evaluation should have been completed on 3/2/2025. RN 1 stated that because of the delay of the evaluation, the facility was not able to provide proper bowel and bladder interventions based on Resident 1 ' s assessment.
b. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/17/2025 and readmitted Resident 3 on 3/30/2025 with diagnoses that included traumatic subdural hemorrhage (bleeding in the area between the brain and the skull usually caused by a head injury) without loss of consciousness (state of being awake and aware of one ' s surroundings), pneumonia (lung infection) and epilepsy (a neurological disorder characterized by recurring seizure [a sudden burst of electrical activity in the brain causing changes in behavior, movement, feelings and level of consciousness]).
During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was moderately impaired. The MDS indicated Resident 3 was dependent (helper does all of the effort and resident does none of the effort to complete activity) on staff with oral hygiene, toileting hygiene, dressing, personal hygiene and mobility (movement).
During a review of Resident 3 ' s Bowel and Bladder assessment dated [DATE], the Bowel and Bladder Assessment indicated Resident 3 was always continent with bladder function and always incontinent (having no or insufficient voluntary control over bowel movements) with bowel function. Further review of Resident 3 ' s Bowel and Bladder Assessment form indicated to complete an evaluation after 72 hours however the evaluation was blank and not completed.
During a concurrent interview and record review on 5/19/2025 at 12:10 p.m., with RN 1, Resident 3 ' s Bowel and Bladder Assessment form dated 3/30/2025 was reviewed. RN 1 stated that Resident 3 ' s Bowel and Bladder Assessment was not completed. RN 1 stated that the 72-hour evaluation portion of Resident 3 ' s Bowel and Bladder Assessment was blank. RN 1 stated that it is important to complete the resident ' s Bowel and Bladder Assessments in a timely manner to ensure that the proper plan of care and interventions for the resident are implemented.
During a review of the facility ' s policy and procedure titled Bowel and Bladder Retraining Program, last reviewed in 8/15/2024, indicated the purpose of the bowel and bladder retraining program is to attempt to assist the incontinent resident regain as much of his or her ability to control bowel and bladder excretory functions.
Feb 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to inform and provide information for two of two 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 inform and provide information for two of two sampled residents (Resident 2 and 3) in advance regarding deep cleaning of their rooms.
This deficient practice had the potential to affect the residents' sense of self-worth, self-esteem, and the resident's right.
Findings:
a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/29/2025 with diagnoses including right knee and right ankle fractures (broken bones) and hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone).
During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 2/4/2025, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact, and the resident needed moderate assistance from staff with toileting hygiene, lower body dressing, bed mobility (movement) and transfer.
During a concurrent observation and interview on 2/14/2025 at 11:48 a.m., with Resident 2, observed Resident 2 sitting on a wheelchair wearing a right leg immobilizer (a medical device used to restrict movement of the joints) in the hallway of the activities room. When Resident 2 was asked when the facility informed Resident 2 that their room would be deep cleaned, Resident 2 stated that Resident 2 was informed on that morning, 2/14/2025. Resident 2 stated the facility did not inform in advance that their room would be deep cleaned, for how long it would take to complete, and why it was being done. Resident 2 was just informed that the room would be cleaned, and Resident 2 would be unable to use it and needed to wait outside of the room on that day at around 9 a.m. and was still waiting in the hallway. Resident 2 stated Resident 2 was wondering if it was to disinfect the room or just regular cleaning, and that no one provided that information, so Resident 2 was wondering why the room needed to be cleaned. Resident 2 further stated that the facility should inform the resident at least one or two days earlier if their room was scheduled for a deep cleaning and the resident would be unable to go in their room for two to three hours. Resident 2 stated the facility should inform the resident the reason for the deep cleaning of the room.
During an interview on 2/14/2025 at 12:21 p.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated that Resident 2's room was scheduled for a deep cleaning on that day, 2/14/2025, and the CNAs did not know the deep cleaning schedule until the day of the deep cleaning. CNA 3 stated that CNA 3 forgot to tell Resident 2 how long the deep cleaning would take and forgot to tell Resident 2 that it was okay to return to their room. CNA 3 stated CNA 3 just informed Resident 2 that the room was scheduled for a deep cleaning then prepared Resident 2 and left Resident 2 in the hallway.
b. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 10/8/2022 and readmitted the resident on 6/18/2023 with diagnoses including Guillain-Barre syndrome (a condition in which the body's immune system attacks the nerves).
During a review of Resident 3's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was intact, and the resident needed moderate assistance from staff with personal/toileting hygiene, upper/lower body dressing, and bed mobility, and total assistance from staff with transfer.
During an interview on 2/14/2025 at 12:01 p.m., with Resident 3 in the resident's room, Resident 3 stated that the facility just completed cleaning their room and Resident 3 was able to come into the room. When Resident 3 was asked if any facility staff informed Resident 3 that their room would be cleaned, Resident 3 stated that the resident was told that morning, 2/14/2025 and was informed Resident 3 would not be able to enter the room for two to three hours. Resident 3 stated Resident 3 was waiting in the activities room. Resident 3 stated the facility should inform Resident 3 at least three days earlier regarding a deep cleaning schedule in order to arrange Resident 3's stuff in the resident's own way. Resident 3 stated there was no time to arrange her stuff then she (Resident 3) was removed from her room.
During an interview on 2/14/2025 at 12:09 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that Resident 3's room was scheduled for a deep cleaning on that day, 2/14/2025. CNA 2 stated housekeeping personnel were informing the residents about the room deep cleaning. CNA 2 stated CNA 2 just assisted Resident 3 out of the room and took Resident 3 to the activities room.
During a review of the facility-provided calendar titled, Deep Clean, dated 2/2025, the calendar indicated Resident 2 and Resident 3's rooms were scheduled for deep cleaning on 2/14/2025.
During a review of the facility-provided deep cleaning signage, the signage indicated, Deep Clean From 8 a.m. to 10 a.m.
During a concurrent interview and record review on 2/14/2025 at 1:55 p.m., with the Housekeeping Supervisor (HS), reviewed the deep cleaning calendar for 2/2025. The HS stated that the HS was the one posting the signage of deep clean from 8 a.m. to 10 a.m. on the residents' room doors on the day of the deep cleaning day, and the nursing staff would inform the residents about the deep cleaning of the rooms. The HS stated that the housekeeping department (HK Dept) had a monthly calendar, but the HK Dept never provided the deep cleaning calendars in advance to the nursing staff.
During an interview on 2/14/2025 at 3:22 p.m., with the Director of Nursing (DON), the DON stated that the facility should have a better system to inform the residents and resident representatives about room cleaning schedules in advance and at least one day earlier with written information. The DON stated sometimes even a temporary room change is needed depending on a resident's condition.
During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed on 8/15/2024, the P&P indicated, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights To receive all information that is material to a resident's decision concerning to accept or refuse any proposed treatment or procedure To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs.
Jan 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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) for one of four sampled residents (Resident 1) when on 1/8/2025, Resident 2 punched Resident 1 in the face several times with a fist (a person's hand when the fingers are bent in toward the palm and held there tightly).
This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a left periorbital (around the eye) discoloration (change in the color, texture or pigmentation of the skin), abrasion (when the surface layers of the skin have been broken) on the left eyebrow, skin tear (a wound that happens when the layers of skin separate or peel back) on the left forearm (part of the arm between the elbow and the wrist) and skin tear on left dorsal (back portion) hand that needed first aid (initial assistance and care given to a resident who has been injured) and daily wound treatments.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 12/5/2024, with diagnoses that included cauda equina syndrome (a rare but serious condition that occurs when the bundle of nerves at the end of the spinal cord becomes damaged), osteomyelitis (bone infection) of the left ankle and foot, cellulitis (a deep infection of the skin caused by bacteria) of the left lower limb (leg).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2024, the MDS indicated Resident 1 had intact cognition (ability to think and make decisions).
During a review of Resident 1's Initial Psychiatric (relating to the medical specialty of psychiatry [branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders]) Evaluation dated 1/8/2025, the Initial Psychiatric Evaluation indicated Resident 1 stated that on the morning of 1/8/2025 at around 9:00 a.m. to 9:30 a.m., he (Resident 1) was trying to sleep when his roommate (Resident 2) hit him (Resident 1) in the face with a fist.
During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a form that provides a framework for communication between members of the health care team about a resident's condition) Communication Form dated 1/8/2025, the SBAR Communication Form indicated on 1/8/2025, Resident 1 was involved in a physical altercation (a confrontation that involves physical force or contact between two or more people) with another resident (Resident 2). The SBAR Communication Form further indicated that as a result of the physical altercation, Resident 1 sustained left periorbital discoloration, left eyebrow abrasion, left forearm skin tear, and left dorsal hand skin tear.
During a review of Resident 1's document titled, Nursing Notes for additional information on the Change of Condition (COC- when there is a sudden change in a resident's condition), dated 1/8/2025, the Nursing Notes indicated that on 1/8/2025, Resident 1 told staff that while he (Resident 1) was trying to sleep, his roommate (Resident 2) struck (hit forcibly) him (Resident 1) out of nowhere and he (Resident 1) used his left arm to block the next strikes. The Nursing Notes further indicated a complete body assessment was done and observed Resident 1 with left eyebrow abrasion 0.8 centimeter (cm- unit of measurement) in length by 0.7 cm in width and 0.1 cm in depth (0.8 cm x 0.7 cm x 0.1 cm), left forearm skin tear 0.8 cm in length by 0.5 cm in width (0.8 cm x 0.5 cm), left dorsal hand skin tear 0.5 cm in length by 0.2 cm in width and 0.1 cm in depth (0.5 cm x 0.2 cm x 0.1 cm), and periorbital discoloration. The Nursing Notes also indicated initial treatment (first aid) was rendered by the nurse (Director of Nursing [DON]) on Resident 1's left eyebrow abrasion and left forearm and dorsal hand skin tears and an ice pack was applied to Resident 1's left eyebrow.
During a review of Resident 1's Skin & Body assessment dated [DATE], the Skin & Body Assessment indicated on 1/8/2025, the assessment was done due to a physical altercation with another resident (Resident 2) and the following injuries were noted:
1. Left eyebrow skin abrasion measuring 0.8 cm x 0.7 cm x 0.1 cm
2. Left forearm skin tear measuring 0.8 cm x 0.5 cm
3. Left dorsal hand skin tear measuring 0.5 cm x 0.2 cm x 0.1 cm
During a review of Resident 1's Order Summary Report, the Order Summary Report indicated there were physician's orders dated 1/8/2025 for the treatment of Resident 1's left eyebrow skin abrasion as follows:
1. Cleanse with normal saline (NS - a liquid solution used to cleanse wounds), pat dry, then, apply steri-strips (thin, sticky bandages applied to the skin to help small cuts or wounds stay closed as they heal) daily, every day shift for seven (7) days.
2. Cleanse with NS, pat dry, then apply xeroform gauze (a medical dressing made of gauze [thin, woven cloth] and petrolatum [skin protectant and moisturizing agent commonly known as petroleum jelly] that is used to treat wounds) and cover with dry dressing (a wound dressing that absorbs moisture from a wound, leaving the area dry) daily, every day shift for seven (7) days.
During a review of Resident 1's Order Summary Report, the Order Summary Report indicated there were physician's orders dated 1/8/2025 for the treatment of Resident 1's left forearm skin tear as follows:
1. Cleanse with NS, pat dry, then apply steri-strips daily, every day shift for seven (7) days.
2. Cleanse with NS, pat dry, then apply xeroform gauze and cover with dry dressing daily, every day shift for seven (7) days.
During a review of Resident 1's Order Summary Report, the Order Summary Report indicated there were physician's orders dated 1/8/2025 for the treatment of Resident 1's left dorsal hand skin tear as follows:
1. Cleanse with NS, pat dry, then apply steri-strips daily, every day shift for seven (7) days.
2. Cleanse with NS, pat dry, then apply xeroform gauze and cover with dry dressing daily, every day shift for seven (7) days.
During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/12/2024, with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that causes blocked airflow from the lungs, making it hard to breathe), unspecified dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), opioid (a class of drugs that can be used to treat pain, but can also be addictive) dependence, and nicotine (an addictive, poisonous chemical found in tobacco) dependence.
During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognition.
During a review of Resident 2's Initial Psychiatric Evaluation dated 1/8/2025, the Initial Psychiatric Evaluation indicated Resident 2 stated that he (Resident 2) had been hearing voices and that on the morning on 1/8/2025, the voice told him (Resident 2) to punch his roommate (Resident 1). The Initial Psychiatric Evaluation further indicated that Resident 2 was agitated (a medical condition that causes a person to feel extremely tense and irritable) and restless (unable to remain still) at times during the evaluation, had impaired insight and judgment, and was having auditory hallucinations (hearing sounds or voices that do not exist in reality).
During a review of Resident 2's SBAR Communication Form dated 1/8/2025, the SBAR Communication Form indicated Resident 2 was physically aggressive towards his roommate (Resident 1), hit his roommate (Resident 1) without apparent reason, and was a danger to himself or others.
During a review of the facility's undated Final Investigative Report, the Final Investigative Report indicated that on 1/8/2025 Resident 1 was in bed when Resident 2 struck him (Resident 1). The Final Investigative Report further indicated that it was confirmed that Resident 2 physically hit Resident 1.
During an interview on 1/21/2025 at 11:30 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 1/8/2025 he (CNA 1) went to answer the call light in Room A (Resident 1 and Resident 2's room) and upon entering the room, he (CNA 1) found Resident 1 lying in bed and rubbing his (Resident 1) left eye. CNA 1 stated Resident 1 told him (CNA 1) that his roommate (Resident 2) hit him (Resident 1).
During an interview on 1/21/2025 at 11:49 a.m., with the Case Manager (CM), the CM stated that on 1/8/2025, he (CM 1) was alerted by CNA 1 that assistance was needed in Room A because there was a resident-to-resident altercation. The CM stated he (CM) assisted in assessing Resident 1 who had told staff that Resident 2 had hit him (Resident 1) while he was sleeping in bed. The CM stated upon assessment of Resident 1, there were skin tears on the left dorsal hand and left forearm, discoloration around the left eye, and an abrasion to the left eyebrow. The CM stated the areas of open skin were not actively bleeding, but the treatment nurse (Licensed Vocational Nurse 1 [LVN 1]) did provide immediate treatment to Resident 1's injuries.
During an interview on 1/21/2025 at 12:30 p.m., with LVN 1, LVN 1 stated he (LVN 1) did not perform the actual treatment (cleanse left eyebrow abrasion and left forearm and left dorsal hand skin tears with NS and place steri-strips on left eyebrow, left forearm, and left dorsal hand) on Resident 1 as he only assisted the DON with measuring and providing treatment to Resident 1's injuries caused by Resident 2.
During an interview on 1/21/2025 at 12:37 p.m., with the DON, the DON stated that on the morning of 1/8/2025, CNA 1 answered Resident 1's call light and after hearing about the altercation, CNA 1 immediately separated Resident 1 and Resident 2 and called the CM for assistance. The DON stated she (DON) was also made aware of the incident and immediately went to Resident 1 to assess him and provide treatment to his (Resident 1) injuries with the assistance of LVN 1. The DON stated that Resident 1 was interviewed and told staff that he (Resident 1) was in bed sleeping when Resident 2 hit him (Resident 1) in the face with his fist. The DON stated Resident 1 further explained to staff that he (Resident 1) used his left arm to cover his face from the other punches from Resident 2. The DON stated that as a result of the altercation, Resident 1 sustained an abrasion on his left eyebrow and skin tears on his left hand and forearm. The DON stated she (DON) measured and provided treatment to Resident 1's abrasion and skin tears. The DON stated she (DON) cleaned Resident 1's left eyebrow abrasion and left forearm and left dorsal hand skin tears with NS and placed steri-strips on Resident 1's left eyebrow, left forearm, and left dorsal hand.
During an interview on 1/21/2025 at 12:55 p.m., with the Social Services Director (SSD), the SSD stated on the morning of 1/8/2025, she (SSD) interviewed Resident 1 after the altercation and Resident 1 told her (SSD) that he was sleeping in bed when Resident 2 charged at him, hitting him in the left eye and left arm. The SSD stated on 1/8/2025, she (SSD) also interviewed Resident 2 after the altercation and Resident 2 admitted to hitting Resident 1, but when asked why he (Resident 2) did it, he did not respond.
During an interview on 1/21/2025 at 3:10 p.m., with the Assistant Administrator (AADM), the AADM stated that he (AADM) was aware of the resident-to-resident altercation between Resident 1 and Resident 2. The AADM stated he (AADM) was involved in the investigation process. The AADM stated that Resident 2 punching Resident 1 in the face several times with a fist is a physical abuse.
During a review of the facility's policy and procedure titled, Abuse Reporting and Prevention, last revised 4/2024, the policy indicated it is the policy of the facility to ensure that residents rights are protected by providing a method of investigation and reporting of alleged violations involving mistreatment, neglect (fail to care for properly), abuse including injuries of unknown sources, unusual occurrences, unauthorized photographs, unauthorized video recordings, unauthorized postings on social media of nursing home residents and misappropriation (intentional, illegal use of the property or funds of a resident for one's own use or other unauthorized purpose) of resident property. The policy and procedure further indicated that the facility is expected to take any necessary action to prevent resident to resident altercations to every extent possible and should be reviewed as a potential situation of abuse. If, during the investigation it is determined that the resident's actions were willful and deliberate, then abuse has occurred.
Dec 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for one of four sampled r...
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Based on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for one of four sampled resident (Resident 2) by failing to follow-up with the physician to obtain an order to continue monitoring Resident 2's surgical wound with non-removable dressing.
This deficient practice had the potential for Resident 2 to have a wound infection.
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted the resident on 11/22/2024 with diagnoses including left hip fracture (broken bone) subsequent (following) encounter for orthopedic (relating to the orthopedics, the medical specialty that treats the bones, muscles, joints, and nerves) aftercare and dementia (a progressive state of decline in mental abilities).
During a review of Resident 2 ' s Minimum Data Set (MDS - a resident assessment tool) dated 11/28/2024, the MDS indicated the resident ' s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS further indicated that the resident was dependent on staff with lower body dressing and needed maximum assistance with bed mobility (movement), and transfer.
During a review of Resident 2 ' s physician order dated 11/23/2024, indicated an order to monitor Resident 2's left hip surgical wound with non-removable dressing for signs and symptoms of infection, every day shift for 14 days, dressing will be removed by the surgeon.
During a review of Resident 2 ' s physician orders summary report, an order dated 12/11/2024 indicated Resident 2 ' s orthopedic follow up appointment was scheduled on 12/13/2024 at 8:30 a.m.
During a concurrent interview and record review on 12/12/2024 at 12:48 p.m., with Treatment Nurse 1 (TN 1), TN 1 reviewed Resident 2 ' s physician order to monitor left hip surgical wound for the signs and symptoms of infection dated 11/23/2024 and Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident) for 12/2024. TN 1 stated that the order was to monitor Resident 2 ' s surgical wound for 14 days from 11/23/2024 to 12/7/2024. TN 1 stated after 12/7/2024, the licensed nurses were no longer documenting monitoring of Resident 2 ' s surgical wound in the TAR. TN 1 stated that he monitored Resident 2 ' s surgical wound but did not document.
During a concurrent observation and interview on 12/12/24 at 1 p.m., in Resident 2 ' s room, TN 1 observed that Resident 2 ' s left hip surgical wound was partially covered with a non-removable dressing and two spots with some staples (small, metal clips called surgical staples to close a cut on the skins). TN 1 stated that did not see the staples yesterday, 12/11/2024, because the surgical wound was completely covered with the non-removable dressing.
During a concurrent interview and record review on 12/12/24 at 1:28 p.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 2 ' s physician order to monitor surgical wound for the signs and symptoms of infection dated 11/23/2024 and the TAR for 12/2024. The ADON stated that the order to monitor surgical wound was for 14 days from 11/23/2024 to 12/7/2024, but a licensed nurse should have reevaluated Resident 2 ' s surgical wound on the 14thday of monitoring and notify the physician of the wound assessment so the physician is aware of the need to continue monitoring the resident ' s wound. The ADON stated if the licensed nurses are not documenting the monitoring of the resident ' s wound, then it is considered as not having been done. The ADON stated that Resident 2 ' s orthopedic follow up appointment was scheduled on 12/13/2024, so Resident 2 ' s surgical wound needed to be monitored by the licensed nurses until the facility staff receive a new order from the orthopedics.
During a review of the facility policy and procedure titled, Wound Care, last reviewed on 8/15/2024, indicated, It is the policy of the facility to provide guidelines for the care of wounds to promote healng Documentation: The following information should be documented in the resident ' s clinical records Right and time under care was given Any change in the resident ' s condition Report other information in accordance with facility policy and professional standards of practice.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure administration of a physician ordered eye drop was accuratel...
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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 administration of a physician ordered eye drop was accurately documented in the Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications given to a resident) for one of four sampled residents (Resident 3).
This deficient practice had the potential to result in confusion in the delivery of care and placed the resident at risk for not receiving the medication as ordered by the physician.
Findings:
During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 10/29/2024 with diagnoses that included glaucoma (eye diseases that can cause vision loss and blindness by damaging a nerve in the back of eyes).
During a review of Resident 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated 11/4/2024, the MDS indicated the resident ' s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS further indicated that the resident needed supervision or touching assistance with oral hygiene and personal hygiene, needed moderate assistance with bed mobility (movement), and needed maximum assistance with transfer.
During a review of Resident 3 ' s physician order summary report, the report indicated an order to instill latanoprost (used to treat certain kinds of glaucoma) ophthalmic (relating to the eyes) solution 0.005 %, or Latanoprost, one drop in both eyes at bedtime for glaucoma.
During an interview on 12/12/2024 at 9:20 a.m., with Resident 3 in the resident ' s room, Resident 3 stated that she did not receive her (Resident 3) eye drops for glaucoma in the evening on the day of her admission.
During a review of 3 ' s Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications given to a resident) for 10/2024, the MAR indicated that Licensed Vocational Nurse 3 (LVN 3) administered Latanoprost to Resident 3 ' s eyes on 10/29/2024 at 9 p.m.
During a concurrent interview and record review on 12/12/24 at 11:20 a.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 3 ' s medication delivery receipt dated 10/30/2024 timed 2:46 a.m. and stated that Resident 3's MAR indicated that LVN 3 documented Resident 3 ' s Latanoprost was administered on 10/29/2024 at 9 p.m., but Resident 3 ' s Latanoprost was delivered to the facility on [DATE] at 2:43 a.m.
During a concurrent interview and record review on 12/12/24 at 3:06 p.m., LVN 3 reviewed Resident 3 ' s MAR for 10/2024 and stated Resident 3 ' s Latanoprost was not delivered on the day of admission, 10/29/2024 and she (LVN 3) incorrectly documented in the MAR that Latanoprost was administered. LVN 3 stated it is important to document medication administration accurately in the MAR to ensure continuity of services to the resident. LVN 3 further stated incorrect documentation of medication administration could result in negative outcomes.
During an interview on 12/12/24 at 4:08 p.m., with the Director of Nursing (DON), the DON stated, if any medications were not available especially on the day of admission, the licensed nurses should have notified the physician the medication was not available and document accurately in the MAR to prevent negative outcomes for the resident
During a review of the facility policy and procedure titled, Medication Administration – General Guidelines, last reviewed on 8/15/2024, indicated, medications are administered in accordance with written orders of the attending physician .the individual who administers the medication dose records the administration on each resident ' s MAR directly after the medication is given .if a dose of regularly medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled, an explanatory note is entered on the reverse side of the record provided for PRN documentation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to:
...
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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 by failing to:
1. Ensure Licensed Vocational Nurse 2 (LVN 2) perform hand hygiene (HH – the practice of cleaning hands to prevent the spread of germs and infections) after checking a resident ' s blood pressure with bare hands for one of four sampled residents (Resident 3).
2. Ensure Treatment Nurse 1 (TN 1) perform hand hygiene between glove changes while providing wound treatment to one of four sampled residents (Resident 4).
These deficient practices had the potential to result in the spread of germs placing residents, staff, and visitors at risk for infection.
Findings:
1. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 10/29/2024 with diagnoses including glaucoma (eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye).
During a review of Resident 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated 11/4/2024, the MDS indicated the resident ' s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS further indicated that the resident needed supervision or touching assistance with oral hygiene and personal hygiene, needed moderate assistance with bed mobility (movement), and needed maximum assistance with transfer.
During a medication pass observation on 12/12/2024, at 8:04 a.m., with LVN 2, observed LVN 2 checking Resident 3 ' s blood pressure with bare hands then returned to the medication cart without performing HH. When LVN 2 was asked what LVN 2 should have done before touching the medication cart, LVN 2 stated she forgot to wear gloves before taking Resident 3 ' s blood pressure and perform HH after taking Resident 3 ' s blood pressure. LVN 2 stated she should have performed HH to reduce the risk of cross contamination (occurs when one object becomes contaminated by either direct or indirect contact with another object which is already contaminated).
2. During a review of Resident 4 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 12/8/2020 and readmitted on [DATE] with diagnoses that included lymphedema (a condition in which lymph builds up in tissues and causes swelling).
During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decision making was intact. The MDS further indicated that the resident needed maximum assistance with upper/lower body dressing and transfer.
During an observation of Resident 4 ' s wound treatment, on 12/12/2024, at 9:38 a.m., with TN 1, observed that TN 1 performed HH and wore gloves before providing Resident 4 ' s wound treatments. TN 1 removed the resident ' s old dressing on the right foot then changed gloves without performing HH, proceeded to clean the wound with normal saline (NS - a solution of water and salt with the concentration of 0.9% sodium chloride) from the inside of the wound to the outside using one stroke each time, applied betadine followed by Santyl (used to remove damaged tissue from chronic skin ulcers), and covered the wound with a new dressing. TN 1 did not perform HH between glove changes. After completing the treatment to the resident ' s right foot, TN 1 changed gloves without performing hand hygiene and proceeded to apply Baza cream (a moisture barrier cream) to Resident 4 ' s right thigh posterior (back) area. After TN 1 completed the wound treatments for Resident 4, TN 1 took off the gloves and washed his hands in the bathroom inside the resident ' s room and documented the treatments provided to the resident.
During a further interview on 12/12/2024 at 9:50 a.m., with TN 1, TN 1 was asked about performing hand hygiene in between glove changes. TN 1 stated that forgot to perform HH between glove changes during wound treatments to Resident 4. TN 1 stated it is important to perform hand hygiene between glove changes to prevent cross contamination.
During an interview on 12/12/2024 at 10:01 a.m., with the Infection Control Preventionist (ICP), the ICP stated that the licensed nurse should perform HH before and after wearing gloves, LVN 2 should perform HH after checking the resident ' s blood pressure and before preparing medications. The ICP further stated that the TNs should perform HH before providing wound treatments, between glove changes during wound treatments, and at the end of the wound treatment services to prevent cross contaminations.
During a review of the facility policy and procedure (P&P) titled, Infection Control Program System, last reviewed on 8/15/2024, the P&P indicated, the facility has an established 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.
During a review of the facility P&P titled, Hand Hygiene, last reviewed on 8/15/2024, indicated, It is the policy of the facility that all staff members perform hand hygiene before and after direct resident care and after contact with the potentially contaminated substances to prevent, to the extent possible, the spread of infection Hand hygiene will be performed by staff as follows Before touching a resident; if gloves will be worn, before gloving; After touching a resident Before and after touching any kinds of wound
Nov 2024
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable services and accommodations for tw...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable services and accommodations for two of three sampled residents (Resident 16 and Resident 28) by failing to:
1. Ensure Resident 16's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach while in bed.
2. Ensure Resident 28 was provided a call light that was adaptive to the resident's needs.
These deficient practices had the potential to delay the provision of services and residents' needs not being met.
Findings:
1. During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 5/20/2024, with diagnoses including, but not limited to chronic obstructive pulmonary disease (COPD - a chronic lung disease that makes it difficult to breathe), dysphagia (difficulty swallowing) following cerebral infarction (a type of stroke that occurs when blood flow to the brain is blocked) and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]).
During a review of Resident 16's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 5/22/2024, the H&P indicated the resident can make needs known but cannot make medical decision.
During a review of Resident 16's Minimum Data Set (MDS- a resident assessment tool), dated 9/21/2024, the MDS indicated the resident needed substantial assistance with activities including eating, hygiene, toileting, dressing, and bathing.
During a review of Resident 16's Care Plan (a written document that summarizes a resident's needs, goals, and care/treatment) titled, Activities of Daily Living (ADL- activities related to personal care) Functional/Rehabilitating Potential, dated 8/27/24, the care plan indicated the call light must be within easy reach.
During a concurrent observation and interview on 11/4/2024 at 8:46 a.m., with Resident 16 in Resident 16's room, observed Resident 16 lying in bed with their call light hanging behind Resident 16's bed and out of Resident 16's reach. Resident 16 stated he did not know where the call light was.
During a concurrent observation and interview on 11/4/2024 at 8:49 a.m., in Resident 16's room with Certified Nursing Assistant 1 (CNA 1), observed Resident 16's call light hanging behind Resident 16's bed and out of reach. CNA 1 stated the call light must always be in reach of the resident so they can have a way to call for assistance if there is an emergency.
During an interview on 11/4/2024 at 11:05 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 16's and all residents' call lights must always be within reach or there could be a delay in care.
2. During a review of Resident 28's admission Record, the admission Record indicated the facility re-admitted the resident on 7/26/2024, with diagnoses including, but not limited to osteomyelitis (a serious bone infection that causes inflammation and swelling in the bone) of vertebra (bones in the spine), type two (2) diabetes mellitus (when sugar level is too high in the blood) with diabetic neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), congestive heart failure (heart is not pumping as well as it should be), and abnormalities of gait (walking) and mobility (movement).
During a review of Resident 28's H&P, dated 7/29/2024, the H&P indicated the resident is alert and oriented times three (knows who they are, the time/date, and where they are) and had the capacity to understand and make decisions.
During a review of Resident 28's MDS dated [DATE], the MDS indicated the resident had impairment on both sides of the upper extremities (shoulder, elbows, wrists, hands) and was dependent on staff for ADLs including eating, hygiene, toileting, dressing, and bathing.
During a concurrent observation and interview on 11/4/2024 at 9:30 a.m., with Resident 28 in Resident 28's room, observed Resident 28 lying in bed with a push button call light on his lap. Resident 28's right wrist was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) with the right hand hyper-extended (when a joint is forced past its normal range of motion typically in the direction opposite to how it naturally bends) backwards towards the left and his left hand contracted with his hand in a mostly closed position. Resident 28 stated he was unable to freely move his arms, wrists and hands or press the button to the call light the facility provided. Resident 28 stated he had to yell out for help to get staff's attention.
During a concurrent observation and interview on 11/4/2024 at 9:45 a.m., in Resident 28's room with Treatment Nurse 1 (TN 1), observed Resident 28's upper extremities and TN 1 confirmed by stating Resident 28 was unable to move his arms without assistance and not able to push the call light button. TN 1 stated Resident 28 could have an emergency and is unable to call for help, causing a delay in care.
During an interview on 11/4/24 at 10:35 a.m., with Registered Nurse 1 (RN 1), RN 1 confirmed by stating Resident 28 needs an adaptive call light and is unable to use the one that Resident 28 currently has, causing a delay in care.
During an interview on 11/4/2024 at 11:05 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the call light Resident 28 currently had was inadequate to Resident 28's needs because Resident 28 was unable to call for assistance, causing a delay in care. The ADON further explained Resident 28 needs to be assessed properly in order to provide the equipment for his limited range of motion.
During a review of the facility's policy and procedure titled, Call Lights, last reviewed on 8/15/2024, the policy 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. It further indicated the resident should be able to return demonstrate how to use the call light.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that an advance directive (AD-written statement of a person's wishes regarding medical treatment made to ensure those wishes are car...
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Based on interview and record review, the facility failed to ensure that an advance directive (AD-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was discussed and written information was provided to the resident and/or responsible parties for one of two sampled resident (Resident 6).
This deficient practice violated the resident's and/or the representative's right to be fully informed of the option to formulate an advanced directive and had the potential to cause conflict with health care wishes.
Findings:
During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 9/11/2024 with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe) and muscle weakness.
During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool) dated 9/17/2024, the MDS indicated the resident had the ability to make self-understood and the ability to understand others.
During a concurrent interview and record review on 11/5/2024 at 3:38 p.m., with the Assistant Director of Nursing (ADON), reviewed a form titled Patient Self-Determination Act of 1990. The review indicated that the Patient Self-Determination Act of 1990 form contained information regarding the resident rights, including the right to formulate an advance directive. The ADON confirmed by stating that Resident 6's Patient Self-Determination Act of 1990 form did not contain Resident 6's signature or resident representative's signature indicating the resident was not informed of their right to formulate an advance directive. The ADON stated the purpose of the form is to inform the residents of their right to formulate an advance directive and if the resident chooses to formulate an advance directive, then their healthcare wishes would be honored as contained in the advance directive. The ADON stated that if there is no signature of the resident acknowledging receipt of the Patient Self-Determination Act of 1990 form with the information regarding their right to formulate an advance directive, then it is a violation of their right and their healthcare wishes may not be upheld or honored.
During a review of the facility's policy and procedure titled, Advance Directives, last reviewed on 8/15/2024, the policy indicated, It is the policy of this facility to promote a resident's right to accept or refuse medical or surgical treatment, and the right to formulate an Advance Directive .upon admission, all residents and their representative are presented with written information about their rights to accept or refuse medical or surgical treatment and their right to formulate and advance directive (if the resident has the capacity to do so). This information is found in the resident rights portion of the admission packet and Preferred Intensity of Care and Advance Directive Acknowledgement forms .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable temperature level for one of four sampled residents (Resident 30).
This deficient practice ha...
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Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable temperature level for one of four sampled residents (Resident 30).
This deficient practice had the potential to result in loss of body heat and risk of hypothermia (dangerously low body temperature) for Resident 30.
Findings:
During a review of Resident 30's admission Record, the admission Record indicated that the facility initially admitted Resident 30 on 2/22/2024 and readmitted the resident on 8/30/2024 with diagnoses including acute embolism and thrombosis of deep veins of the right lower extremity (a clinical condition in which blood clots [a gel-like clump of blood] are forming and affecting the veins and arteries in the right lower extremity), degenerative disease of nervous system (a condition where the nerves or brain gradually break down or stop working properly over time), and repeated falls.
During a review of Resident 30's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 2/23/2024, the H&P indicated that the resident did not have the capacity to understand and make decisions.
During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 10/17/2024, the MDS indicated that the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated that Resident 30 was dependent on the assistance of two or more helpers for showering, and required maximal assistance for toileting, personal hygiene, dressing and chair-to-bed transfer, and was not able to walk.
During a concurrent observation and interview on 11/4/2024 at 9:42 a.m., in Resident 30's room, Resident 30 was observed laying down in his bed, covered with a blanket and stated that he is cold in his room.
During a concurrent observation and interview on 11/4/2024 at 9:51 a.m., with the Maintenance Supervisor Assistant (MSA) in Resident 30's room, the MSA took the temperature of Resident 30's room. The MSA stated Resident 30's room temperature was 68 degrees Fahrenheit (unit of measurement of temperature). The MSA stated that the temperature should between 70-75 degrees Fahrenheit.
During an interview on 11/7/2024 at 10:15 a.m., with the Maintenance Supervisor (MS), the MS stated that there was an open window in the bathroom, which was why the temperature in Resident 30's room was below 70 degrees Fahrenheit. The MS stated that temperature should be maintained in a safe and comfortable range between 70-75 degrees Fahrenheit.
During an interview on 11/7/2024 at 12:20 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that the temperature in the residents' rooms has to be at a safe and comfortable level for all residents.
During a review of the facility's policy and procedure titled, Comfortable Environment, last reviewed on 8/15/2024, the policy indicated, The facility will maintain the temperature at a comfortable level for residents, which is generally 70-75 degrees Fahrenheit, or it can be adjusted to whatever they feel is comfortable level.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a written docume...
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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 person-centered care plan (a written document that summarizes a resident's needs, goals, and care/treatment) for two of three sampled residents (Resident 28 and 50) by failing to:
1. Develop a care plan addressing Resident 28's range of motion (ROM - the amount of movement that a particular joint or series of joints can achieve in a specific direction) limitations.
2. Develop a care plan addressing Resident 50's bowel and bladder incontinence (a problem holding in urine or stool).
These deficient practices had the potential to result in failure to deliver the necessary care and services.
Findings:
a. During a review of Resident 28's admission Record, the admission Record indicated the facility re-admitted the resident on 7/26/2024, with diagnoses including, but not limited to osteomyelitis (a serious bone infection that causes inflammation and swelling in the bone) of vertebra (bones in the spine), type two (2) diabetes mellitus (when sugar level is too high in the blood) with diabetic neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), congestive heart failure (heart is not pumping as well as it should be), and abnormalities of gait (walking) and mobility (movement).
During a review of Resident 28's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 7/29/2024, the H&P indicated the resident is alert and oriented times three (knows who they are, the time/date, and where they are) and had the capacity to understand and make decisions.
During a review of Resident 28's Minimum Data Set (MDS, a resident assessment tool), dated 9/21/2024, the MDS indicated the resident had impairment on both sides of the upper extremities (shoulder, elbows, wrists, hands) and was dependent on staff for Activities of Daily Living (ADLs- activities related to personal care) including eating, hygiene, toileting, dressing, and bathing.
During a concurrent observation and interview on 11/4/2024 at 9:30 a.m., with Resident 28 in Resident 28's room, observed Resident 28 lying in bed with a push button call light on his lap. Resident 28's right wrist was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) with the right hand hyper-extended (when a joint is forced past its normal range of motion typically in the direction opposite to how it naturally bends) backwards towards the left and his left hand contracted with his hand in a mostly closed position. Resident 28 stated he was unable to freely move his arms, wrists and hands or press the button to the call light the facility provided. Resident 28 stated he had to yell out for help to get staff's attention.
During a concurrent observation and interview on 11/4/2024 at 9:45 a.m., in Resident 28's room with Treatment Nurse 1 (TN 1), observed Resident 28's upper extremities and TN 1 confirmed by stating Resident 28 was unable to move his arms without assistance and not able to push the call light button. TN 1 stated Resident 28 could have an emergency and is unable to call for help, causing a delay in care.
During a concurrent interview and record review on 11/4/2024 at 10:35 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 28's care plans from 7/26/2024 to 11/4/2024 and Resident 28's Initial Nursing History and Assessment form dated 7/26/2024. RN 1 stated there was no care plan to address Resident 28's upper extremity ROM limitations. RN 1 stated she assessed Resident 28 when he was readmitted to the facility on [DATE] and missed notating Resident 28's upper extremity ROM limitations on the Initial Nursing History and Assessment form.
During an interview on 11/4/2024 at 11:05 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 28 should have an ADL care plan that accurately reflects the resident's ROM limitations.
During a review of the facility's policy and procedure titled, Comprehensive Care Planning, last reviewed on 8/15/2024, the policy 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 care plan is based upon the resident assessment and choices and must be reviewed and revised at least quarterly on an ongoing basis to reflect any changes in the resident.
b. During a review of Resident 50's admission Record, the admission Record indicated the facility originally admitted the resident on 10/8/2022 and readmitted the resident on 6/18/2023, with diagnoses that included but not limited to, gastroesophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach) and dysphagia (difficulty swallowing).
During a review of Resident 50's MDS dated [DATE], the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact and required moderate assistance from staff for toileting, shower, dressing and personal hygiene. The MDS also indicated that the resident is frequently incontinent of bowel and bladder.
During a concurrent interview and record review on 11/6/2024 at 10:00 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 50's MDS dated [DATE] and care plans dated 10/8/2022 to 11/6/2024. Section H of Resident 50's MDS indicated Resident 50 is frequently incontinent of bowel and bladder. RN 2 stated there was no care plan for Resident 50's bowel and bladder incontinence and stated there should be a care plan. RN 2 stated that a care plan would clearly identify the incontinence problem, set a goal and a timeframe in resolving the problem, and come up with interventions to attain the goals. RN stated the care plan would also include an evaluation date to review the effectiveness of the care plan and if not then revise the care plan with additional interventions to meet the goals of treatment. RN 2 stated that in the absence of a care plan for bowel and bladder incontinence, the care needs of the resident may not be provided which could result in skin breakdown or impairment due to uncontrolled passage of urine and stool.
During a review of the facility's policy and procedure titled, Comprehensive Care Planning, last reviewed on 8/15/2024, the policy 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 care plan is based upon the resident assessment and choices and must be reviewed and revised at least quarterly on an ongoing basis to reflect any changes in the resident.
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. During a review of Resident 30's admission Record, the admission Record indicated that the facility initially admitted Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 30's admission Record, the admission Record indicated that the facility initially admitted Resident 30 on 2/22/2024 and readmitted the resident on 8/30/2024 with diagnoses including acute embolism and thrombosis of the deep veins of the right lower extremity (a clinical conditions in which blood clots [a clump of blood that has changed from liquid to gel-like state, which can block blood flow] is forming and affecting the veins and arteries in the right lower extremity), degenerative disease of the nervous system (a condition where the nerves or brain gradually break down or stop working properly over time), and repeated falls.
During a review of Resident 30's History and Physical, (H&P) dated 2/23/2024, the H&P indicated that the resident did not have the capacity to understand and make decisions.
During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 10/17/2024, the MDS indicated that the resident had severely impaired cognition (a severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 30 was dependent on the assistance of two or more helpers for showering, required maximal assistance for toileting and personal hygiene, dressing and chair-to-bed transfer, and was not able to walk.
During a review of Resident 30's Care Plan (CP-written guide that organizes information about the resident's care), dated 10/9/2024, the CP indicated that Resident 30 was complaining of a burning sensation upon urination. The CP interventions indicated to administer medication as ordered and reevaluate the resident on 10/12/2024.
During a review of Resident 30's Situation, Background, Assessment and Recommendation communication tool (SBAR-a structured communication framework that can help teams share information about the condition of a patient the team needs to address), dated 10/9/2024, the SBAR indicated the resident had pain when urinating. The SBAR indicated that Physician 1 was informed and orders for urinalysis (UA- a test of a urine sample to check for infection) and Urine Culture and Sensitivity (C&S- a test to find out if there is bacteria in the urine that may be causing an infection and the best antibiotic [a type of medication to treat infection caused by bacteria] for the infection) were received and placed.
During a review of Resident 30's Urine C&S result, dated 10/13/2024, the Urine C&S result indicated that the resident's urine had more than 100000 colonies/ml Proteus Mirabilis (a significant number of bacteria that can cause urinary tract infection).
During a review of Resident 30's Nursing Notes, dated 10/10/2024, 10/11/2024 and 10/12/2024, the Nursing Notes indicated that the resident did not have any pain or burning sensation during urination.
During a concurrent interview and record review on 11/7/2024 at 9:52 AM with the Infection Preventionist (IP), the Surveillance Data Collection Form, dated 10/9/2024, was reviewed. The Surveillance Data Collection Form indicated that Resident 30's symptom of burning sensation was resolved in last three days and the urine culture result was forwarded to the Medical Doctor (MD) on 10/13/2024 and no new order for antibiotics was received as of 10/14/2024. The IP stated that Resident 30's care plan for burning sensation during urination should have been resolved on 10/14/2024 to ensure the care plan was accurate and based on resident's needs.
During an interview with the Assistant Director of Nursing (ADON) on 11/7/2024 at 12:20 PM, the ADON stated that Resident 30's care plan for burning sensation during urination should have been resolved after three days of monitoring to reflect Resident 30's assessment and needs.
During a review of the facility Policy and Procedure (P&P) titled Care Planning- Interdisciplinary Team, last reviewed on 8/15/2024, the P&P indicated: The care plan is based on the resident 's needs and the resident's comprehensive assessment and is developed by a Care planning /Interdisciplinary team.
Based on interview and record review, the facility failed to:
a. Ensure the Interdisciplinary Team (IDT-a group of experts from various disciplines working together to treat your ailment, injury, or chronic health condition) involve the resident on two quarterly IDT Care Conference for one of one resident (Resident 50) investigated under Care Planning.
This deficient practice deprived the resident's right to be included in developing a resident-centered care plan (a treatment plan that is based on the needs, preferences, and habits of each resident) which had the potential to result in failure to deliver the necessary care and services.
b. Revise the care plan for burning sensation during urination when the resident's symptoms resolved after three days of monitoring for one of three sampled residents (Resident 30).
This deficient practice had the potential for Resident 30 to receive inappropriate care and services.
Findings:
a. During a review of Resident 50's admission Record, the admission Record indicated the facility originally admitted the resident on 10/08/2022 and readmitted on [DATE], with diagnoses including gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining) and dysphagia (difficulty swallowing).
During a review of Resident 50`s Minimum Data Set (MDS - a resident assessment tool), dated 10/10/2024, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact and required moderate assistance from staff for toileting, shower, dressing and personal hygiene. The MDS also indicated that the resident is frequently incontinent of bowel and bladder.
During a concurrent interview record review and on 11/06/24 at 10:00 a.m., with Registered Nurse 2 (RN 2), reviewed the Quarterly IDT Care Plan (a document that summarizes a person's health conditions, care needs, and current treatments) Conference Summary dated 4/11/2024 and 7/11/2024. The Quarterly IDT Care Plan Conference Summary indicated the care plan conference was attended by representatives from the departments of Nursing, Social Services, Dietary, Activity and by Resident 50's family member via telephone. The Quarterly IDT Care Plan Conference Summary indicated the care plan conference was conducted to update the care plans and to review the consents. RN 2 confirmed that the resident was not involved in these care plan conferences. RN 2 stated that there is no documentation that the resident was invited or had refused to attend the care plan conference. RN 2 stated that given that the resident has intact cognitive function and has not appointed anyone as her representative, she (Resident 50) should have been included in the care plan conference. RN 2 stated that it is the right of the resident to participate in developing her (Resident 50) care plan to ensure the care plan is resident-centered and include the resident`s input. RN 2 stated that, if the resident's input was not addressed, the care plan might not address the resident's needs.
During a review of the facility`s policy and procedures (P&P) titled Policy for the Interdisciplinary Team, last reviewed on 8/15/2024, the P&P indicated that It is the policy of the facility that the 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 guardian are encouraged to participate in the development and revisions to the resident`s care plan .every effort will be made to schedule care plan meeting at the best time of day for the resident and the resident`s family .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to comprehensively assess the limited mobility and range of motion (RO...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to comprehensively assess the limited mobility and range of motion (ROM - the amount of movement that a particular joint or series of joints can achieve in a specific direction) for one of two residents (Resident 28) when the resident was readmitted on [DATE].
This deficient practice resulted in Resident 28 not having the appropriate equipment to maintain their maximum practicable independence and had the potential to cause further decline in functional mobility, ROM, and quality of life.
Findings:
During a review of Resident 28's admission Record, the admission Record indicated the facility re-admitted the resident on 7/26/2024, with diagnoses including, but not limited to osteomyelitis (a serious bone infection that causes inflammation and swelling in the bone) of vertebra (bones in the spine), type two (2) diabetes mellitus (when sugar level is too high in the blood) with diabetic neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), congestive heart failure (heart is not pumping as well as it should be), and abnormalities of gait (walking) and mobility (movement).
During a review of Resident 28's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 7/29/2024, the H&P indicated the resident is alert and oriented times three (knows who they are, the time/date, and where they are) and had the capacity to understand and make decisions.
During a review of Resident 28's Minimum Data Set (MDS, a resident assessment tool), dated 9/21/2024, the MDS indicated the resident had impairment on both sides of the upper extremities (shoulder, elbows, wrists, hands) and was dependent on staff for Activities of Daily Living (ADLs- activities related to personal care) including eating, hygiene, toileting, dressing, and bathing.
During a concurrent observation and interview on 11/4/2024 at 9:30 a.m., with Resident 28 in Resident 28's room, observed Resident 28 lying in bed with a push button call light on his lap. Resident 28's right wrist was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) with the right hand hyper-extended (when a joint is forced past its normal range of motion typically in the direction opposite to how it naturally bends) backwards towards the left and his left hand contracted with his hand in a mostly closed position. Resident 28 stated he was unable to freely move his arms, wrists and hands or press the button to the call light the facility provided. Resident 28 stated he had to yell out for help to get staff's attention.
During a concurrent observation and interview on 11/4/2024 at 9:45 a.m., in Resident 28's room with Treatment Nurse 1 (TN 1), observed Resident 28's upper extremities and TN 1 confirmed by stating Resident 28 was unable to move his arms without assistance and not able to push the call light button. TN 1 stated Resident 28 could have an emergency and is unable to call for help, causing a delay in care.
During a concurrent interview and record review on 11/4/2024 at 10:35 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 28's Initial Nursing History and Assessment form dated 7/26/2024. RN 1 stated she assessed Resident 28 when he was readmitted to the facility on [DATE] and missed notating Resident 28's upper extremity ROM limitations on the Initial Nursing History and Assessment form.
During an interview on 11/4/2024 at 11:05 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the call light Resident 28 currently had been using was inadequate for Resident 28's needs because Resident 28 was unable to call for assistance, causing a delay in care. The ADON further explained Resident 28 needs to be assessed properly in order to provide the equipment for Resident 28's limited range of motion.
During a concurrent interview and record review on 11/6/2024 at 11:00 a.m., with the Director of Rehab (DOR), reviewed Resident 28's Occupational Therapy Evaluation and Plan of Treatment dated 7/30/2024. The DOR confirmed by stating that although the right wrist, hand and fingers were assessed as impaired, there was no recommendation for an adaptive call light for Resident 28's needs. The DOR further stated Resident 28's left hand, wrist and fingers ROM limitations were missed because the plan of treatment indicated they were within functional limitations when Resident 28's MDS dated [DATE] indicated limitations and Resident 28 stated he was never able to push a call button at that time. The DOR stated every resident must be assessed thoroughly and correctly to provide them with the appropriate care and equipment.
During a review of the facility's policy and procedure titled, Call Lights, last reviewed on 8/15/2024, the policy 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. It further indicates the resident should be able to return demonstrate how to use the call light.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure a fall risk evaluation was completed after...
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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 a fall risk evaluation was completed after a fall on 8/29/2024 and ensure the fall risk evaluation completed on 9/6/2024 was accurate for one of four sampled resident (Resident 30).
This deficient practice had the potential to negatively affect Resident 30's plan of care and the delivery of necessary care and services.
2. Ensure Licensed Vocational Nurse 5 (LVN 5), who was administering medications to a resident, did not leave the prepared medications unattended at the resident's bedside for one of 23 sampled residents (Resident 197).
This deficient practice had the potential to result in unauthorized personnel or residents having access to the resident's medications.
Findings:
1. During a review of Resident 30's admission Record, the admission Record indicated that the facility initially admitted Resident 30 on 2/22/2024 and readmitted the resident on 8/30/2024 with diagnoses including acute embolism and thrombosis of deep veins of the right lower extremity (a clinical condition in which blood clots [a gel-like clump of blood] are forming and affecting the veins and arteries in the right lower extremity), degenerative disease of nervous system (a condition where the nerves or brain gradually break down or stop working properly over time), and repeated falls.
During a review of Resident 30's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 2/23/2024, the H&P indicated that the resident did not have the capacity to understand and make decisions.
During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 10/17/2024, the MDS indicated that the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated that Resident 30 was dependent on the assistance of two or more helpers for showering, and required maximal assistance for toileting, personal hygiene, dressing and chair-to-bed transfer, and was not able to walk.
During a review of Resident 30's Nursing Notes, dated 8/29/2024, the Nursing Notes indicated Resident 30 was found in the resident's room, sitting on the floor by Certified Nurse Assistant and was sent to General Acute Care Hospital 1 (GACH 1) for evaluation.
During a review of Resident 30's physician order, dated 8/29/2024, the physician order indicated an order to transfer Resident 30 to GACH 1 emergency room (ER) for further evaluation related to status post (after a significant event, procedure, or treatment) non-witnessed fall.
During a review of Resident 30's Care Plan (a written document that summarizes a resident's needs, goals, and care/treatment), dated 8/29/2024, the care plan indicated that Resident 30 had an actual fall incident.
During concurrent interview and record review on 11/7/2024 at 12:20 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 30's Fall Risk Evaluations dated 2/22/2024, 4/22/2024, 6/7/2024, 8/19/2024, and 9/6/2024. The ADON stated that Resident 30 did not have a Fall Risk Evaluation completed on 8/29/2024 after the actual fall. The ADON stated that the Fall Risk Evaluation dated 9/6/2024 was not accurate because it indicated that there were no falls in the past three months. The ADON further stated that it was important to perform a Fall Risk Evaluation after the fall on 8/29/2024 and accurately calculate the fall risk score in order to make a fall risk care plan accurate with measurable objectives to meet the resident's needs and desired outcomes.
During a review of the facility's policy and procedure titled, Fall Risk /Prevention, last reviewed on 8/15/2024, the policy indicated, It is the policy of the facility to identify residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls .The Fall Risk Assessment will be reviewed quarterly and after each fall.
2. During a review of Resident 197's admission Record, the admission Record indicated the facility admitted the resident on 10/24/2024 with diagnoses including encephalopathy (a general term for a group of brain disorders that can affect the brain's structure or function) and gastrostomy (a surgical procedure that creates an opening in the abdomen and into the stomach to insert a feeding tube) status.
During a review of Resident 197's H&P dated 10/30/2024, the H&P indicated that the resident did not have the capacity to understand and make decisions.
During a review of Resident 197's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (thought processes) and required maximal assistance from staff for most activities of daily living (ADLs - activities related to personal care).
During an observation on 11/5/2024 at 8:07 a.m., observed LVN 5 prepare medications for Resident 197. Observed LVN 5 leave the prepared medications at the resident's bedside behind the privacy curtain while LVN 5 returned to the medication cart for a stethoscope (a medical instrument for listening to the action of someone's heart or breathing).
During an interview on 11/5/2024 at 8:51 a.m., with LVN 5, LVN 5 confirmed by stating that he had left the prepared medications unattended and out of eyesight at Resident 197's bedside.
During an interview on 11/7/2024 at 9:59 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that licensed nurses administering medications should not leave medications out of eyesight because another resident may have unauthorized access to them and experience adverse side effects (undesired harmful effect resulting from a medication or other intervention) or an allergic reaction.
During a review of the facility's policy and procedure titled, Medication Administration - General Guidelines, last reviewed and revised on 8/15/2024, the policy indicated that during administration of medications, the medication cart is kept closed, locked, and secure. Medications need to be secured and locked when unattended.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on interview and record review Licensed Vocation Nurse 1 (LVN 1) failed to ensure that residents who needed respiratory care (the health care discipline that specializes in the promotion of opti...
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Based on interview and record review Licensed Vocation Nurse 1 (LVN 1) failed to ensure that residents who needed respiratory care (the health care discipline that specializes in the promotion of optimum cardiopulmonary function and health and wellness) were provided such care, consistent with professional standards of practice to one out of three sampled residents (Residents 242) by failing to:
1. Ensure that the suction catheter (a flexible hallow tube used to remove secretions from a patient's airway) was covered with a sleeve when not in use.
2. Administer oxygen (a colorless, odorless, and tasteless gas, that support life) to Resident 242 according to the physician order.
3. Label Resident 242's suction tubing with the date for when it was last changed.
These deficient practices had the potential to cause respiratory infection to Resident 242.
Findings:
During a review of Resident 242's admission Record, the admission Record indicated that the facility initially admitted Resident 242 on 10/4/2024 and readmitted the resident on 10/11/2024 with diagnoses including malignant neoplasm of the colon (the development of cancer in the colon), acute systolic heart failure (when the heart muscle cannot pump enough blood to meet the body's needs), acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury), and pleural effusion (a condition where too much fluid builds up in the space between lungs and chest wall).
During a review of Resident 242's History and Physical (H&P), dated 10/11/2024, the H&P indicated that the resident had the capacity to understand and make decisions.
During a review of Resident 242's Minimum Data Set (MDS - a resident assessment tool) dated 10/17/2024, the MDS indicated that the resident had severely impaired cognition (a severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS indicated that Resident 242 needed supervision for eating, maximal assistance for dressing, oral and toileting hygiene, and was dependent on assistance of two or more helpers for showering.
During a review of Resident 242's Physician Order, dated 10/11/2024, the Physician Order indicated the following orders:
1. Continuous administration of oxygen at 2 litters per minute (L/min-measurement of oxygen flow) via nasal canula (a device that gives additional oxygen through the nose) to keep oxygen saturation (a percentage of oxygen-saturated hemoglobin [a protein in red blood cells that carries oxygen from lungs to the body's tissues and organs] in the blood compared to total hemoglobin) above 94%.
2. Suction as needed (PRN) for increase secretion (the making and release of substances by glands).
During an observation on 11/4/2024, at 10:50 AM, Resident 242 was observed in his room in a wheelchair with no oxygen being administered to the resident.
During a concurrent observation and interview on 11/4/2024 at 10:52 AM with Licensed Vocational Nurse 2 (LVN 2), observed Resident 30's oxygen concentrator not connected to the resident, the suction tubing connected to the cannister not labeled with the date when it was last changed, and the suction catheter tip stored in Resident 242's nightstand drawer not covered with a sleeve. LVN 2 checked the Physician order and stated that oxygen had to be continuously administered to Resident 242 via nasal canula at 2 L/min to keep the oxygen saturation over 94%. LVN 2 checked Resident 242's oxygen saturation, and it was at 93%. LVN 2 connected the oxygen to Resident 242 via nasal canula at 2 L/min. LVN 2 stated that the suction tubing had to be labeled with the date when it was last changed and that the suction catheter should be covered with a sleeve to prevent contamination (the act of making something unclean or harmful) after use.
During an interview on 11/7/2024 at 12:20PM with the Assistant Director of Nursing (ADON), the ADON stated that oxygen should have been administered to Resident 242 according to the Physician order, the suction tubing should have been labeled with date when it was last changed, and the suction catheter should have been covered with a sleeve when not in use to prevent Resident 42 from potentially getting a respiratory infection.
During a review of the facility Policy and Procedure (P&P) named Physician Services, last reviewed on 8/15/2024, the P&P indicated: Drugs, biologicals, laboratory services, radiology and other diagnostic services shall be administered or performed only upon the written order of a person duly licensed and authorized to prescribe such drugs and services.
During a review of the facility Policy and Procedure named Oxygen Concentration, last reviewed on 8/15/2024, the P&P indicated : Cannulas should be replaced weekly.
CONCERN
(D)
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 administer pain medication as prescribed by the physician for one of sampled resident (Resident 6).
This deficient practice had the potenti...
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Based on interview and record review, the facility failed to administer pain medication as prescribed by the physician for one of sampled resident (Resident 6).
This deficient practice had the potential to result in adverse consequences (undesired harmful effect resulting from a medication or other intervention).
Findings:
During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 9/11/2024 with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe) and muscle weakness.
During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool) dated 9/17/2024, the MDS indicated the resident had the ability to make self-understood and the ability to understand others.
During a review of Resident 6's physician's orders, the physician's orders indicated an order for hydrocodone-acetaminophen (Norco- brand name; used to relieve moderate to severe pain) oral tablet 10-325 milligram (mg- unit of measurement) one tablet by mouth every four (4) hours as needed for severe pain 7-10/10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain) not to exceed 3 grams (g- unit of measurement) per 24 hours.
During a concurrent interview and record review on 11/5/2024 at 10:46 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 6's Medication Administration Record (MAR- includes key information about the individual's medication including, the medication name, dose taken, special instructions and date and time) for 10/2024. The review indicated that on 10/4/2024 at 3:59 a.m. and 10/19/2024 at 4:46 p.m., Resident 6 was administered Norco 10-325 mg when Resident 6's pain level was zero (0) on both occasions. RN 2 stated on 10/4/2024 and 10/19/2024, Resident 6's pain level did not indicate that Norco 10-325 mg should be administered since Resident 6's pain level was zero. RN 2 stated that the pain level must reflect the severity of the pain for Norco 10-325 mg to be administered to avoid unnecessary use of the medications as it causes adverse consequences such as constipation (problem with passing stool), respiratory depression (when you breathe too slowly or too shallowly), and sedation (a state of calmness, relaxation, or sleepiness caused by certain drugs) which could lead to fall and injury.
During a review of the facility's list of Medication Issues of Particular Relevance in Older Adults, undated, the document indicated hydrocodone under Opioid Analgesics, which can have adverse consequences including, constipation, nausea, vomiting, sedation, lethargy (a state of unusual drowsiness, lack of energy, and mental alertness), weakness, confusion, physical and psychological dependency (form of addiction that involves an emotional or mental attachment to a substance), and unintended respiratory depression.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to complete a post-dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [org...
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Based on interview and record review, the facility failed to complete a post-dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of one sampled resident (Resident 13).
This deficient practice placed Resident 13 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions).
Findings:
During a review of Resident 13's admission Record, the admission Record indicated the facility admitted the resident on 7/18/2024 with diagnoses including, but not limited to end stage renal disease (when the kidneys can no longer filter blood properly), dependence on renal (kidney) dialysis.
A review of Resident 13's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 7/19/2024, the H&P indicated the resident did not have the capacity to make decisions.
A review of Resident 13's Minimum Data Set (MDS- a resident assessment tool), dated 10/18/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding), and required substantial/maximal assistance with all activities of daily living (ADLs - activities related to personal care). The MDS indicated Resident 13 was on dialysis.
During a concurrent interview and record review on 11/5/2024 at 8:49 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 13's Nursing Facility Pre and Post Dialysis Assessment forms. LVN 1 verified by stating Resident 13's post dialysis assessment was not completed on 10/24/2024 and there was no documentation for vital signs and assessment of the access site. LVN 1 stated the charge nurses are responsible for completion of the form upon resident arrival in the facility to ensure there were no signs of complication such as abnormal vital signs, bleeding, and/or altered mental status (change in mental function).
During an interview on 11/6/2024 at 10:49 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the licensed nurses are responsible to complete the post dialysis assessment part of the Nursing Facility Pre and Post Assessment form upon resident's return to the facility and should include the vital signs and signs or symptoms of bleeding to ensure that the resident is stable and there are no signs of complications.
During a review of the facility's policy and procedure titled, Dialysis Care, last reviewed 8/15/2024, the policy indicated the Post Dialysis Checklist part of this form is to be completed by the facility upon return of the resident. Information to be documented includes:
a. Vital signs.
b. Information regarding the type of access site and condition of the dressing and access site.
c. Skin condition and any skin tears, discoloration or pressure ulcers noted.
d. Any additional instructions from the dialysis unit.
e. Any additional comments and signature of the licensed nurse, date and time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' low air loss mattresses (LALM, a ma...
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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' low air loss mattresses (LALM, a mattress designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) were set at the correct setting for three of 23 sampled residents (Residents 88, 11, and 196).
This deficient practice had the potential to place the resident at risk for discomfort and development of pressure ulcers/injuries (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure).
Findings:
a. During a review of Resident 88's admission Record, the admission Record indicated the facility admitted Resident 88 on 2/28/2023 and readmitted the resident on 10/2/2024 with diagnoses including fracture (broken bone) of the left femur (the thigh bone), fracture of the left pubic bone (a broken bone in the front part of left hip), fracture of the left ulna (a broken bone in the left forearm), and diabetes type two (2) (a chronic condition that affects the way the body processes blood glucose [sugar]).
During a review of Resident 88's History and Physical (H&P - a medical document that records a resident's detailed medical history, including their current symptoms and past health conditions, along with a physical examination conducted by a healthcare provider to assess their overall health status), dated 10/3/2024, the H&P indicated that the resident had a fluctuating (to change or vary) capacity to understand and make decisions.
During a review of Resident 88's Minimum Data Set (MDS- a resident assessment tool) dated 10/8/2024, the MDS indicated the resident's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was mildly impaired (a slight decline in mental abilities, memory and completing complex tasks) and the resident needed supervision or set assistance for eating, oral and personal hygiene, and maximal assistance for toileting hygiene, dressing, and showering.
During a review of Resident 88's Care Plan (a written document that summarizes a resident's needs, goals, and care/treatment) dated 10/2/2024, the care plan indicated that the resident was at high risk for further skin break down related to decreased mobility. The interventions of the care plan indicated to use a LALM as a pressure relieving device.
During a review of Resident 88's physician's orders, the document indicated a physician order dated 10/4/2024 to apply a LALM for skin management.
During a concurrent observation and interview on 11/4/2024 at 10:08 a.m., with Licensed Vocational Nurse 7 (LVN 7) in Resident 88's room, observed Resident 88's LALM set to 210 pounds (lbs. - unit of measurement of weight). LVN 7 stated the LALM was supposed to be set to Resident 88's weight, around 140 lbs. LVN 7 stated the LALM is an intervention to promote wound healing and prevent further pressure injuries. LVN 7 stated if the LALM is not set at the correct setting then it won't be effective and there is the potential the resident may develop further pressure injuries.
During an interview on 11/7/2024 at 12:20 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that it was important to follow the physician's order for the correct settings of the LALM for each resident. The ADON stated if the LALM is not set at the correct setting then it won't be effective and there is a potential the resident may develop further skin injuries.
During a review of the LALM's Operator's Manual, undated, the manual indicated that LALM is designed for wound care therapy treatment and prevention. Further, the manual indicated to turn the pressure adjust knob to set a comfortable pressure level by using the weight as a guide.
b. During a review of Resident 11's admission Record, the admission Record indicated the facility admitted the resident on 6/21/2024 with diagnoses including fracture (broken bone) of the shaft of the left femur (thigh bone) and orthopedic (relating to the branch of medicine dealing with the correction of deformities of bones or muscles) aftercare.
During a review of Resident 11's H&P dated 6/2024, the H&P indicated that the resident had the capacity to understand and make decisions.
During a review of Resident 11's MDS dated [DATE], the MDS indicated the resident had intact cognition and required maximal assistance from staff for most activities of daily living (ADLs - activities related to personal care). The MDS also indicated the resident was at risk of developing pressure ulcers/injuries.
During a review of Resident 11's physician's orders, dated 7/22/2024, the physician's orders indicated an order to provide the resident with an LALM for wound management.
During a review of Resident 11's Weights and Vitals Summary, dated 10/14/2024, the Weight and Vitals Summary indicated Resident 11 weighed 132 lbs.
During an observation on 11/4/2024 at 9:26 a.m., observed Resident 11 asleep in bed with Resident 11's LALM set to firm, or greater than 350 lbs.
During an interview on 11/4/2024 at 9:31 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 11 had a current physician's order to have an LALM for wound management.
During an interview on 11/4/2024 at 9:39 a.m., with Treatment Nurse 1 (TN 1), TN 1 stated Resident 11 had a physician's order for an LALM to prevent the development of wounds. TN 1 stated the LALM should have been set between 80 - 150 lbs. TN 1 stated it was the facility's practice to set the LALM according to the resident's current weight in order to prevent wound development.
During an interview on 11/7/2024 at 9:59 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that the purpose of a LALM was to manage residents' wounds or prevent them from developing wounds. The ADON stated that LALM should be set according to the residents' weight. The ADON stated that if residents' LAL mattresses were incorrectly set, then it increased their risk for skin breakdown.
During a review of the LALM's Operator's Manual, undated, the manual indicated to turn the pressure adjust knob to set a comfortable pressure level by using the weight scale as a guide.
During a review of the facility's policy and procedure titled, Wound Care, last reviewed and revised on 8/15/2024, the policy indicated it was the policy of the facility to provide guidelines for the care of wounds to promote healing.
c. During a review of Resident 196's admission Record, the admission Record indicated the facility admitted the resident on 10/29/2024 with diagnoses including osteomyelitis (a serious bone infection), difficulty in walking, and generalized muscle weakness.
During a review of Resident 196's H&P, dated 10/30/2024, the H&P indicated that the resident has the capacity to understand and make decisions.
During a review of Resident 196's MDS, dated [DATE], the MDS indicated the resident had intact cognition and required maximal assistance from staff for most ADLs.
During a review of Resident 196's physician's order, dated 11/7/2024, the physician's order indicated that the resident may have a low air loss mattress.
During a review of Resident 196's care plan for stage III pressure ulcer (a deep wound that extends through the skin and into the fat tissue, but doesn't reach the muscle, tendon, or bone) on the right and left buttock, initiated on 10/30/2024, the care plan indicated for the use of a LALM.
During an observation on 11/4/2024 at 9:47 a.m., observed Resident 196 in bed with Resident 196's LALM set to 280 lbs.
During a concurrent observation and interview on 11/4/2024 at 10:48 a.m., with TN 1, TN1 observed and verified by stating that Resident 196's LALM was set to 280 lbs. TN 1 stated Resident 196 had a stage III pressure ulcer on her buttock, and the mattress should have been set according to Resident 196's weight, which was 133 lbs.
During an interview on 11/7/2024 at 9:59 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that the purpose of a LALM was to manage residents' wounds or prevent them from developing wounds. The ADON stated that LALM should be set according to the residents' weight. The ADON stated that if residents' LAL mattresses were incorrectly set, then it increased their risk for skin breakdown.
During a review of the LALM's Operator's Manual, undated, the manual indicated to turn the pressure adjust knob to set a comfortable pressure level by using the weight scale as a guide.
During a review of the facility's policy and procedure titled, Wound Care, last reviewed and revised on 8/15/2024, the policy indicated it was the policy of the facility to provide guidelines for the care of wounds to promote healing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure leftover food brought from outside by resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure leftover food brought from outside by resident's family and visitors were labeled with a resident identifier and use-by date for three of four residents (Resident 76, 83, and 192).
This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for the residents.
Findings:
a. During a review of Resident 76's admission Record, the admission Record indicated the facility admitted the resident on 7/30/2024 with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and morbid obesity (is when you weigh more than 80 to100 pounds above your ideal body weight).
During a review of Resident 76's Minimum Data Set (MDS - a resident assessment tool), dated 8/05/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS also indicated that the resident required substantial/maximal assistance with toileting hygiene, shower, lower body dressing and putting on and taking off footwear.
b. During a review of Resident 83's admission Record, the admission Record indicated the facility admitted the resident on 8/24/2024 with diagnoses that included hypertension and glaucoma (a group of eye conditions that can cause blindness).
During a review of Resident 83's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was intact. The MDS also indicated that the resident required moderate assistance with toileting hygiene, shower, lower body dressing, putting on and taking off footwear.
c. During a review of Resident 192's admission Record, the admission Record indicated the facility admitted the resident on 10/22/2024, with diagnoses that included muscle weakness and chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems).
During a review of Resident 192's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was intact. The MDS also indicated that the resident required substantial/maximal assistance with toileting hygiene, shower, lower body dressing and putting on and taking of footwear.
During a concurrent facility kitchen observation and interview on 11/4/2024 at 8:07 a.m., with the Dietary Manager (DM), observed food containers in different shapes and colors in the residents' refrigerator. The DM stated the following:
- Red container with unidentifiable food content belonging to Resident 76 with no use-by date.
- Orange container with pancake, bacon, spoon and fork with no resident name and no use-by date.
- [NAME] plastic container with food content that is not identifiable belonged to Resident 192, with no use-by date.
- Clear plastic container with bread and sliced turkey belonging to Resident 83 with no use-by date.
The DM then stated that leftover food from outside that is kept in the resident refrigerator must be labeled with resident identifier and dated to ensure it is discarded by the use-by date. The DM stated that consuming leftover food wherein the date the food was brought in and prepared is unknown, can potentially make the resident sick with foodborne illnesses. The DM stated when food items are placed in the refrigerator, the food items must be dated and labeled with the resident's name.
During a review of the facility's policy and procedure titled, Food for Residents from Outside Sources, last reviewed on 8/15/2024, the policy indicated, .prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, nursing station's refrigerator or in the residents' personal refrigerator. In the food service department, the policy on food storage will apply. Otherwise, if unopened, refrigerated, or frozen items will be disposed of by the expiration date on the container. If opened, the food must be sealed, date to the date opened and disposed in 2 days after opening .
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** 3. During a review of Resident 30's admission Record, the admission Record indicated that the facility initially admitted Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 30's admission Record, the admission Record indicated that the facility initially admitted Resident 30 on 2/22/2024 and readmitted the resident on 8/30/2024 with diagnoses including acute embolism and thrombosis of deep veins of the right lower extremity (a clinical condition in which blood clots [a gel-like clump of blood] are forming and affecting the veins and arteries in the right lower extremity), degenerative disease of nervous system (a condition where the nerves or brain gradually break down or stop working properly over time), and repeated falls.
During a review of Resident 30's H&P, dated 2/23/2024, the H&P indicated that the resident did not have the capacity to understand and make decisions.
During a review of Resident 30's MDS dated [DATE], the MDS indicated that the resident had severely impaired cognition. The MDS further indicated that Resident 30 was dependent on the assistance of two or more helpers for showering, required maximal assistance for toileting and personal hygiene, dressing and chair-to-bed transfer, and was not able to walk.
During an observation on 11/4/2024 at 9:42 a.m., in Resident 30's room, Resident 30 was observed laying down in his bed with urinals observed on the left side of the bed, not labeled with Resident 30's name.
During a concurrent observation and interview on 11/4/2024 at 9:43 a.m., in Resident 30's room, with Restorative Nurse Assistant 1 (RNA 1), observed Resident 30 laying in bed with urinals on the left side of the bed. RNA 1 stated that urinals have to be labeled with the resident's name to prevent cross contamination.
During an interview on 11/7/2024 at 12:20 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that according to the facility's policy, all urinals have to be labeled with resident's name. The ADON stated not labeling the urinals may lead to the spread of infection in the facility.
During a review of the facility's policy and procedure titled, Facility Rules, reviewed on 8/15/2024, the policy indicated, All clothing and personal items for residents should be labeled with resident's first and last name, for example grooming supplies, toothbrushes, urinals, etc.
Based on observation, interview, and record review, the facility failed to:
1. Ensure Licensed Vocational Nurse 5 (LVN 5) donned (put on) a gown before administering medications via gastrostomy tube (g-tube - a flexible tube that is surgically inserted through the abdominal wall and into the stomach) to a resident on enhanced barrier precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) for one of 23 sampled residents (Resident 197).
2. Ensure Certified Nursing Assistant 2 (CNA 2) performed hand hygiene (the practice of washing or sanitizing your hands to prevent the spread of disease and infection) after picking up a dirty towel from the floor and before assisting a resident with lunch for one of 23 sampled residents (Resident 53).
3. Label a urinal (a handled container used to collect urine) with the resident's name for one of 23 sampled resident (Resident 30).
These deficient practices had the potential to place the residents at increased risk of developing an infection.
Findings:
1. During a review of Resident 197's admission Record, the admission Record indicated the facility admitted the resident on 10/24/2024 with diagnoses including encephalopathy (a general term for a group of brain disorders that can affect the brain's structure or function) and gastrostomy (a surgical procedure that creates an opening in the abdomen and into the stomach to insert a feeding tube) status.
During a review of Resident 197's History and Physical (H&P - a medical document that records a resident's detailed medical history, including their current symptoms and past health conditions, along with a physical examination conducted by a healthcare provider to assess their overall health status), dated 10/30/2024, the H&P indicated that the resident did not have the capacity to understand and make decisions.
During a review of Resident 197's Minimum Data Set (MDS - a resident assessment tool), dated 10/30/2024, the MDS indicated the resident had severely impaired cognition (thought processes) and required maximal assistance from staff for most activities of daily living (ADLs - activities related to personal care).
During an observation on 11/5/2024 at 8:07 a.m., observed LVN 5 administering medications to Resident 197 via g-tube and not wearing a gown.
During an interview on 11/5/2024 at 8:51 a.m., with LVN 5, LVN 5 stated he should have donned a gown prior to administering medications to Resident 197 via g-tube since they were on EBP.
During an interview on 11/7/2024 at 1:30 p.m., with the Infection Preventionist (IP), the IP stated that any resident with an indwelling (a device that is left inside the body) medical device was placed on EBP. The IP stated it was important for staff to wear proper PPE in order to protect them from any bodily fluids they may come into contact with when performing any type of care to the resident. The IP stated this included administering medications via g-tube. The IP stated that staff and residents may be at increased of spreading infection if proper PPE is not worn during care of residents on EBP.
During a review of the facility's policy and procedure titled, Enhanced Standard Precautions (ESP), last reviewed and revised on 8/15/2024, the policy indicated that the purpose of enhanced standard precautions is a resident-centered and activity-based approach for preventing MDRO transmission in skilled nursing facilities (SNF). The California Department of Public Health (CDPH) recommends the use of ESP, primarily the use of gowns and gloves for specific high contact care activities, based on the resident's characteristics that are associated with a high risk of MDRO colonization (when a microorganism [organism that can only been seen with a microscope] is present in or on a host but it doesn't cause disease or symptoms) and transmission, such as the presence of indwelling devices (e.g. urinary catheter [a flexible tube that drains urine from the bladder into a bag], feeding tube, endotracheal or tracheostomy tube [a curved tube that's inserted into the windpipe to help keep it open and allow air to reach the lungs], and vascular catheters [a thin, flexible tube that's inserted into a vein to provide access to the bloodstream]).
2. During a review of Resident 53's admission Record, the admission Record indicated the facility admitted the resident on 10/4/2024 with diagnoses including paranoid schizophrenia (a type of schizophrenia [mental disorder in which people interpret reality abnormally ] that involves paranoia [a pattern of behavior where a person feels distrustful and suspicious of other people]).
During a review of Resident 53's H&P, dated 10/6/2024, the H&P indicated that the resident had the capacity to understand and make decisions.
During a review of Resident 53's MDS, dated [DATE], the MDS indicated the resident had intact cognition and required moderate assistance for most ADLs.
During an observation on 11/4/2024 at 12:19 p.m., observed a resident drop a towel on the floor in the dining room, and observed Certified Nursing Assistant 2 (CNA 2) pick it up from the floor and hand it to another staff member. Observed CNA 2 then bring Resident 53's lunch tray to the resident and assisted Resident 53 with opening and unwrapping food items on the tray. CNA 2 did not perform hand hygiene between picking up the dirty towel from the floor and serving lunch to Resident 53.
During an interview on 11/4/2024 at 12:25 p.m., with CNA 2, CNA 2 verified by stating that she (CNA 2) picked up the dirty towel from the floor and then proceeded to serve lunch to Resident 53 without performing hand hygiene. CNA 2 stated she (CNA 2) should have performed hand hygiene before assisting the resident with lunch.
During an interview on 11/4/2024 at 1:30 p.m., with the IP, the IP stated that facility staff have been educated to perform hand hygiene before and after assisting residents with their lunch tray. The IP stated that the purpose of performing hand hygiene was to prevent the spread of infection in order to ensure that residents do not get sick.
During a review of the facility's policy and procedure titled, Hand Hygiene, last reviewed and revised on 8/15/2024, the policy indicated that all staff members perform hand hygiene before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infection.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. - unit of mea...
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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 at least 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident bedrooms for four of 38 resident rooms (Rooms 1, 3, 9, and 11). Rooms 1, 3, 9, and 11 all have two beds in each room.
This deficient practice had the potential to result in inadequate useable living space for all the residents and inadequate working space for the health caregivers.
Findings:
During a review of the Request for Room Size Waiver letter dated 11/1/2024, submitted by the Administrator, the letter indicated the rooms (room [ROOM NUMBER], 3, 9, and 11) did not meet the 80 square feet requirement per federal regulation. The letter indicated the resident beds were in accordance with the special needs of the residents and will not adversely affect the residents' health and safety and do not impede the ability of the residents in that room to obtain their highest practicable well-being. The letter indicated the following:
The following rooms provided less than 80 square feet per resident:
Rooms
# Beds
Floor Area Sq. Ft.
Sq. Ft/Resident
1
2
146
73
3
2
155
77.5
9
2
143
71.5
11
2
151
75.5
The minimum square footage for a 2-bed room should be 160 sq. ft.
During the resident council (a group of nursing home residents who meet regularly to discuss their rights, quality of care, and quality of life) meeting on 11/5/2024 at 10 a.m., no concerns were brought up by the residents regarding the size of the rooms.
During the general observation of the residents' rooms on 11/5/2024 and 11/6/2024, the residents had ample space to move freely inside the rooms. There were sufficient space to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There was also sufficient space for beds, side tables, and resident care equipment.
Oct 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 policy and procedure for an allegation of financial 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 implement its policy and procedure for an allegation of financial abuse for one of three sampled residents (Resident 1) by failing to:
1.
conduct a thorough investigation of the alleged financial abuse.
2.
provide documented evidence that a Situation, Background, Assessment and Recommendation (SBAR - a communication tool that helps provide essential, concise information about the condition of a resident) Form was completed.
3.
ensure Resident 1 was monitored every shift for 72 hours for emotional distress or negative outcome as a result of the alleged financial abuse.
These deficient practices had the potential to place Resident 1 at risk for further abuse and could have resulted in Resident 1 needing care or emotional support which was not provided.
Findings:
During a review of Resident 1's admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included hydrocephalus (a condition where too much cerebrospinal fluid [CSF- a clear, colorless, watery fluid that flows in and around your brain and spinal cord to help cushion the brain and spinal cord from injury and provide nutrients] builds up in the brain), and Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). Resident 1's admission Record further indicated Resident 1's son (Family Member 1 [FM 1]), was Resident 1's financial power of attorney (POA - legal authorization for a designated person to make decisions about another person's property, finances, or medical care).
During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/21/2024 indicated Resident 1 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses).
During a review of Resident 1's [NAME] Statement with a billing date of 10/3/2024 indicated the following due balance:
a.
August 2024 - balance due was $8,716.50.
b.
September 2024 - balance due was $2,357.00.
c.
October 2024 - balance due was $2,357.00.
d.
Total Balance due as of 10/3/2024 billing date was $13,430.50.
During an interview on 10/21/2024 at 1:27 p.m., with the Business Office Manager (BOM), the BOM stated that she reported an allegation of financial abuse to the SSA on Resident 1's behalf after confirming and being aware on 10/3/2024 that FM 1 was receiving Resident 1's Social Security check (a monthly payment from the federal government that replaces part of a person's income when they retire or become disabled), but was not paying Resident 1's Share of Cost (the monthly amount an individual is responsible to pay towards their medical related services and supplies before Medi-Cal [a public health insurance program which provides needed health care services for limited income individuals] will begin to pay). The BOM stated that FM 1 informed her (BOM) that he (FM 1) could not pay for Resident 1's share of cost because FM 1 was using the money for his (FM 1's) daughter's school expenses. The BOM stated she (BOM) considered this as financial abuse because FM 1 was using Resident 1's money for his (FM 1) own personal expenses, instead of using it towards Resident 1's medical expenses. The BOM stated she (BOM) followed the facility's abuse policy and informed the Administrator (ADM), who is the abuse coordinator.
During a concurrent interview and record review on 10/21/2024 at 1:30 p.m., with the Medical Records Director (MRD), Resident 1's SBAR forms from 7/11/2024 to 10/21/2024 were reviewed. The MRD stated there was no SBAR completed related to Resident 1's allegation of financial abuse.
During an interview on 10/21/2024 at 2:01 p.m., with the Administrator (ADM), the ADM stated that he (ADM) did not conduct a formal investigation and did not complete a conclusion letter regarding the allegation of financial abuse reported on 10/3/2024 to the SSA. The ADM stated he (ADM) investigated through conversations with FM 1 but did not document anything. The ADM stated he understood the regulations and the policy of the facility and knew it was his (ADM) responsibility to thoroughly investigate the allegation of abuse and report the results of his investigation to the Department within five days. The ADM stated he did not think a formal typed up investigation and conclusion letter was needed since he (ADM) was in constant communication with FM 1 and Resident 1's goal of being discharged to an assisted living facility (ALF - a type of long-term care facility that provides housing, meals, and personal care support to a group of full-time residents) was met.
During an interview on 10/21/2024 at 3:45 p.m. with the Director of Nursing (DON), the DON stated that the nursing department was unaware that there was a report of financial abuse made on behalf of Resident 1. The DON stated had Resident 1 verbalized abuse or had she (DON) been made aware of the financial abuse report, the nursing department would have completed an SBAR, developed a plan of care including interventions such as reporting to the physician, conducting an assessment and ensuring Resident 1 was monitored every shift for 72 hours for emotional distress or possible negative outcome as a result of the alleged financial abuse. However, she (DON) was not made aware, hence, nothing was done.
A review of the policy and procedure titled, Abuse Reporting and Prevention, last revised in 04/2024, indicated it is the policy of the facility to ensure that alleged violations by anyone in the facility involving mistreatment, neglect, or abuse including misappropriation of resident property are reported to the administrator of the facility. The policy and procedure further indicated that the ADM, as the abuse coordinator, will investigate each alleged violation thoroughly and report results to appropriate agencies and personnel. The results of the investigation must be reported within five (5) working days of the incident. In addition, the policy and procedure indicated the following interventions be completed in response to the allegation of abuse:
· Initiate a physical and mental assessment of the resident and document objective findings.
· Notify the resident's attending physician regarding the alleged incident.
· Initiate a care plan to reflect the resident's condition.
· Complete an incident report.
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 policies and procedures for ensuring the reporting of a r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to ensure the results of the abuse investigation for the allegation of financial abuse that occurred on 10/3/2024 was reported to the State Survey Agency (SSA) within five (5) working days for one (1) of three (3) 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 indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included hydrocephalus (a condition where too much cerebrospinal fluid [CSF- a clear, colorless, watery fluid that flows in and around your brain and spinal cord to help cushion the brain and spinal cord from injury and provide nutrients] builds up in the brain), and Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). Resident 1's admission Record further indicated Resident 1's son (Family Member 1 [FM 1]), was Resident 1's financial power of attorney (POA - legal authorization for a designated person to make decisions about another person's property, finances, or medical care).
During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/21/2024 indicated Resident 1 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses).
During a review of Resident 1's [NAME] Statement with a billing date of 10/3/2024 indicated the following due balance:
a.
August 2024 - balance due was $8,716.50.
b.
September 2024 - balance due was $2,357.00.
c.
October 2024 - balance due was $2,357.00.
d.
Total Balance due as of 10/3/2024 billing date was $13,430.50.
During an interview on 10/21/2024 at 1:27 p.m., with the Business Office Manager (BOM), the BOM stated that she reported an allegation of financial abuse to the SSA on Resident 1's behalf after confirming and being aware on 10/3/2024 that FM 1 was receiving Resident 1's Social Security check (a monthly payment from the federal government that replaces part of a person's income when they retire or become disabled), but was not paying Resident 1's Share of Cost (the monthly amount an individual is responsible to pay towards their medical related services and supplies before Medi-Cal [a public health insurance program which provides needed health care services for limited income individuals] will begin to pay). The BOM stated that FM 1 informed her (BOM) that he (FM 1) could not pay for Resident 1's share of cost because FM 1 was using the money for his (FM 1's) daughter's school expenses. The BOM stated she (BOM) considered this as financial abuse because FM 1 was using Resident 1's money for his (FM 1) own personal expenses, instead of using it towards Resident 1's medical expenses. The BOM stated she (BOM) followed the facility's abuse policy and informed the Administrator (ADM), who is the abuse coordinator.
During an interview on 10/21/2024 at 2:01 p.m., with the Administrator (ADM), the ADM stated that he (ADM) did not conduct a formal investigation and did not complete a conclusion letter regarding the allegation of financial abuse reported on 10/3/2024 to the SSA. The ADM stated he (ADM) investigated through conversations with FM 1 but did not document anything. The ADM stated he understood the regulations and the policy of the facility and knew it was his (ADM) responsibility to thoroughly investigate the allegation of abuse and report the results of his investigation to the Department within five days. The ADM stated he did not think a formal typed up investigation and conclusion letter was needed since he (ADM) was in constant communication with FM 1 and Resident 1's goal of being discharged to an assisted living facility (ALF - a type of long-term care facility that provides housing, meals, and personal care support to a group of full-time residents) was met.
A review of the policy and procedure titled, Abuse Reporting and Prevention, revised 04/2024, indicated it is the policy of the facility to ensure that alleged violations by anyone in the facility involving mistreatment, neglect, or abuse including misappropriation of resident property are reported to the administrator of the facility. The policy and procedure further indicated that the ADM, as the abuse coordinator, will investigate each alleged violation thoroughly and report results to appropriate agencies and personnel. The results of the investigation must be reported within five (5) working days of the incident.
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 a comprehensive person-centered care plan (a written course...
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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 comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1), who was involved in an allegation of financial abuse.
This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.
Findings:
During a review of Resident 1's admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included hydrocephalus (a condition where too much cerebrospinal fluid [CSF- a clear, colorless, watery fluid that flows in and around your brain and spinal cord to help cushion the brain and spinal cord from injury and provide nutrients] builds up in the brain), and Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). Resident 1's admission Record further indicated Resident 1's son (Family Member 1 [FM 1]), was Resident 1's financial power of attorney (POA - legal authorization for a designated person to make decisions about another person's property, finances, or medical care).
During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/21/2024 indicated Resident 1 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses).
During a review of Resident 1's [NAME] Statement with a billing date of 10/3/2024 indicated the following due balance:
a.
August 2024 - balance due was $8,716.50.
b.
September 2024 - balance due was $2,357.00.
c.
October 2024 - balance due was $2,357.00.
d.
Total Balance due as of 10/3/2024 billing date was $13,430.50.
During a concurrent interview and record review on 10/21/2024 at 1:30 p.m., with the Medical Records Director (MRD), Resident 1's care plans from 7/11/2024 to 10/21/2024 were reviewed. The MRD stated there was no care plan developed in related to Resident 1's allegation of financial abuse.
During a concurrent interview and record review on 10/21/2024 at 2:35 p.m., with the Director of Staff Development (DSD), Resident 1's care plans from 7/11/2024 to 10/21/2024 were reviewed. The DSD stated she (DSD) could not find a care plan that addressed Resident 1's alleged financial abuse. The DSD stated that a care plan is created in response to all abuse allegations and there should have been a care plan developed for Resident 1's alleged financial abuse. The DSD stated it was important to have a care plan addressing Resident 1's alleged abuse in order for interventions to be placed to maintain Resident 1's psychosocial well-being (the state of mental, emotional, and social health of an individual).
During an interview on 10/21/2024 at 3:45 p.m. with the Director of Nursing (DON), the DON stated that the nursing department was unaware that there was a report of financial abuse made on behalf of Resident 1. The DON stated had Resident 1 verbalized abuse or had she (DON) been made aware of the financial abuse report, the nursing department would have developed a plan of care including interventions such as reporting to the physician, conducting an assessment, and ensuring Resident 1 was monitored every shift for 72 hours for emotional distress or possible negative outcome as a result of the alleged financial abuse. However, she (DON) was not made aware, hence, a care plan was done.
A review of the facility's policy and procedure titled, Comprehensive Care Planning, last revised in 1/2017 indicated it is the policy of the facility to develop a comprehensive care plan for each resident. The policy and procedure further indicated the plan of care must include measurable objectives and timeframes and describe the services that are to be furnished to attain and maintain the resident's highest practicable level of well-being.
A review of the policy and procedure titled, Abuse Reporting and Prevention, last revised 04/2024, indicated one of the interventions to be completed in response to an allegation of abuse is to initiate a care plan to reflect the resident's condition.
Sept 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (harsh and insulting language directed at a person) by Certified Nursing Assistan...
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Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (harsh and insulting language directed at a person) by Certified Nursing Assistant 1 (CNA 1) towards one of five sampled residents (Resident 1). On 9/7/2024, CNA 1 hurled (to utter) an obscene word (a curse word that is a socially offensive use of language) at Resident 1.
This deficient practice resulted in Resident 1 being subjected to verbal abuse while under the care of the facility and had the potential to cause emotional harm which could result to a feeling of low self-esteem and self-worth.
Findings:
During a review of Resident 1's admission Record indicated that the facility admitted the resident on 7/20/2024 with diagnoses including, but not limited to, osteomyelitis (bone infection) of the ankle and foot and type two diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with foot ulcer (an open wound or sore that can be difficult to heal).
During a review of Resident 1's History and Physical (H&P), dated 7/20/2024, indicated that Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/26/2024, indicated Resident 1 was cognitively (can remember, learn new things, concentrate, and make decisions that affect their everyday life) intact. The MDS indicated Resident 1 needed supervision with personal hygiene and moderate assistance with toileting hygiene, shower/bathing, and lower body dressing. The MDS further indicated Resident 1 can walk ten feet with moderate assistance. The MDS indicated walking 50 or more feet was not attempted due to Resident 1's medical condition or safety concerns.
During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a form used to facilitate prompt and appropriate communication regarding the condition of a resident or issues that needs to be addressed) Communication Form dated 9/7/2024 at 6:20 p.m., indicated Resident 1 was in a verbal altercation with CNA 1 where they (Resident 1 and CNA 1) stood along the hallway, face to face and exchanged heated words in a loud manner.
During an interview on 9/10/2024 at 11:03 a.m. with Resident 1, Resident 1 stated that he (Resident 1) became upset after he asked CNA 1 for a cup of coffee. Resident 1 stated that CNA 1 would not bring a cup of coffee to him. Resident 1 stated that he then stood up and CNA 1 stated, look, you can walk! in a condescending (showing or characterized by a patronizing or superior attitude toward others) way and started giving Resident 1 directions to the kitchen. Resident 1 stated he became upset, and he and CNA 1 both started arguing. Resident 1 stated he could see that CNA 1 was talking back to him, but he could not hear what CNA 1 was saying because he was yelling.
During an interview on 9/10/2024 at 12:07 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that he heard Resident 1 and CNA 1 yelling at each other. LVN 1 stated he heard Resident 1 say, fuck you, to which CNA 1 replied, fuck you, too. LVN 1 stated he immediately separated Resident 1 and CNA 1 and reported the incident to Registered Nurse (RN) 1.
During an interview on 9/10/2024 at 2:27 p.m. with the Administrator (ADM) and Director of Nursing (DON), the ADM stated that CNA 1 was out of line and that the language used by CNA 1 to Resident 1 was verbal abuse, but it wasn't abusive. ADM stated Resident 1 threatened the CNA, and CNA 1 couldn't handle it. The ADM stated CNA 1 should have walked away, and DON stated CNA 1 was disrespectful.
During a review of the facility's policy and procedure (P&P) titled, Abuse Reporting and Prevention, last reviewed April 2024, the P&P indicated verbal abuse is defined as the use of written, oral, or gestured language that willfully used derogatory or disparaging terms regardless of their age, ability to comprehend, or disability. The P&P further indicated alleged violations are to be investigated and reported to ensure resident rights are protected.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the primary care physician (Primary Medical Doctor 1 [P...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the primary care physician (Primary Medical Doctor 1 [PMD 1]) for one of four sampled residents (Resident 1), who had a history of hypothyroidism (a condition where the thyroid gland doesn't release enough thyroid hormone [plays a role in regulating weight, energy levels, growth and metabolism] into the bloodstream), reviewed Resident 1's General Acute Care Hospital 1 (GACH 1) progress notes, including medications essential to Resident 1's medical treatment. PMD 1 failed to prescribed Resident 1 her (Resident 1) routine medication (medication taken regularly) of Levothyroxine (a medication used to treat an underactive thyroid gland [a gland that makes and stores hormones that help regulate the heart rate, blood pressure, body temperature, growth development and energy) upon admission to the facility on 5/26/2024.
This deficient practice resulted in Resident 1 not receiving 30 doses of Levothyroxine from 5/26/2024 to 6/25/2024. Subsequently, Resident 1 was transferred to General Acute Care Hospital 2 (GACH 2) where Resident 1 was diagnosed with myxedema coma (severe hypothyroidism leading to decreased mental status [mental capacity], hypothermia [dangerously low body temperature], and other symptoms related to slowing of function in multiple organs) requiring Resident 1 to be admitted into the Intensive Care Unit (ICU- a unit in a hospital providing intensive care for critically ill patients) on 6/25/2024.
Findings:
During a review of Resident 1's admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypothyroidism.
During a review of Resident 1's History and Physical (H&P) from GACH 1, completed by PMD 1, dated 5/23/2024, the H&P indicated that Resident 1 was admitted to GACH 1 on 5/23/2024. Listed under Resident 1's medical history was a diagnosis of hypothyroidism. The H&P further indicated that Resident 1's routine home medications included Levothyroxine 100 micrograms (mcg-unit of measure), one tablet to be taken by mouth once a day.
During a review of Resident 1's H&P completed by PMD 1 (same physician in charge of Resident 1's care while in the facility), dated 5/26/2024, the H&P indicated that Resident 1 did not have the capacity to understand and make decisions. The H&P further indicated that Resident 1's medical history included a diagnosis of hypothyroidism.
During a review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 6/1/2024, the MDS indicated that Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS further indicated that Resident 1 required set up assistance with eating; supervision with oral hygiene; moderate assistance with personal hygiene; and maximum assistance with toileting hygiene and bathing.
During a review of Resident 1's Physician Orders from 5/26/2024 to 6/25/2024, the Physician Orders for Resident 1 did not indicate an order for Levothyroxine.
During a review of Resident 1's Change of Condition (COC- a sudden deviation from a resident's health status) dated 6/25/2024, the COC indicated that on 6/25/2024 at 9:52 a.m., Resident 1 passed out in the shower room. The COC further indicated at 9:54 a.m., Resident 1 regained consciousness (the state of being awake and aware of one's surrounding) and was verbally responsive. On 6/25/2024 at 10:07 a.m., 911 (telephone number to reach emergency services) was called, and on 6/25/2024 at 10:22 a.m., paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) arrived at the facility, took over Resident 1's care and transferred Resident 1 to GACH 2.
During a review of Resident 1's Discharge Summary (DS) from GACH 2, dated 7/5/2024, the DS indicated that Resident 1 was admitted to GACH 2 on 6/25/2024 with diagnoses that included myxedema coma. The DS indicated that Resident 1 had a history of thyroidectomy (surgical removal of all or part of the thyroid gland) and was previously prescribed Levothyroxine, but Levothyroxine was not continued for the past several months. The DS indicated that Resident 1 had severely elevated thyroid stimulating hormone (TSH- a blood test that measures thyroid stimulating hormone [normal TSH level is 0.5 to 5.0 milli-internal units per liter {mIU/L- unit of measure}]) and low thyroxine test (T4- a blood test that measures the level of thyroxine in the blood [normal T4 level is 0.8 to 1.9 nanograms per deciliter {ng/dL-unit of measure}]) dated 6/26/2024. Resident 1 was found to have profound (to the greatest possible degree) hypothyroidism and myxedema coma with an initial TSH level drawn on 6/26/2024, TSH level greater than 150 mIU/L. Resident 1 was initiated on Levothyroxine intravenous (into the vein). The DS also indicated that Resident 1's thyroid function was noted to be severely affected.
During an interview on 7/24/2024 at 11:48 a.m. with PMD 1, PMD 1 stated that he (PMD 1) was the primary care physician for Resident 1 during Resident 1's stays at GACH 1 and at the facility. PMD 1 stated that Resident 1 had a history of hypothyroidism. When PMD 1 was asked if PMD 1 reviewed Resident 1's routine home medications that indicated that Resident 1 was taking Levothyroxine, PMD 1 stated that he (PMD 1) did not review Resident 1's routine home medications list. PMD 1 stated that had if he (PMD 1) reviewed Resident 1's routine home medications list, PMD 1 would have noted that Resident 1 was prescribed Levothyroxine and PMD 1 would have continued Resident 1's previously prescribed Levothyroxine. PMD 1 further stated it's a big problem Resident 1 ended up with myxedema coma as a result of the lack of Levothyroxine, an essential medication needed for Resident 1's diagnosis of hypothyroidism.
During an interview and concurrent record review on 7/24/2024 at 12:10 p.m. with the Director of Nursing (DON), the DON reviewed Resident 1's H&P from GACH 1, completed by PMD 1, dated 5/23/2024 and Resident 1's H&P at the facility, completed by PMD 1, dated 5/26/2024, and Resident 1's Physician Orders from 5/26/2024 to 6/25/2024. The DON verified the Physician Orders for Resident 1 did not indicate an order for Levothyroxine. The DON stated PMD 1 did not prescribe Resident 1 Levothyroxine throughout Resident 1's stay at the facility. The DON stated PMD 1 should have reviewed Resident 1's total program of care including the list of medications and treatments upon admission to GACH 1 and upon admission to the facility vital to Resident 1's health and well-being.
During a review of the facility policy and procedure (P&P), titled Physician Services and Orders dated January 2017, last reviewed on 8/17/2023, the P&P indicated that it is the policy of the facility that each resident remain under the care of a physician. Drugs, biologicals, laboratory services, radiology and other diagnostic services shall be administered or performed only upon the written order of a person duly licensed and authorized to prescribe such drugs and services .The physician must review the resident's total care at each visit, write, sign and date progress notes and sign and date all orders. This includes reviewing medications and treatments.
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of four sampled resident ' s (Resident 2) urinary drainage bag (bag that collects a resident ' s urine) was not pl...
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Based on observation, interview, and record review, the facility failed to ensure one of four sampled resident ' s (Resident 2) urinary drainage bag (bag that collects a resident ' s urine) was not placed above the resident ' s bladder (organ inside the body that stores urine).
This deficient practice had the potential to result in urine flowing back into the resident ' s bladder which would then increase the risk for a urinary tract infection (an infection in any part of the urinary system) that can cause serious health problems such as sepsis (a serious condition in which the body responds improperly to an infection and a potentially life-threatening complication).
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 1/28/2024 with diagnoses including chronic kidney disease (CKD - a condition in which the kidneys are damaged and cannot filter blood as well as they should), 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).
A review of Resident 2's History and Physical (H&P) dated 1/30/2024, indicated that Resident 2 had a history of urinary retention (the inability to voluntarily void [empty] urine). The H&P further indicated Resident 2 did not have decision making capacity.
A review of Resident 2 ' s Physician ' s Order dated 1/29/2024, indicated to change Resident 2's indwelling catheter (a tube which is inserted into the bladder that allows urine to drain) if clogged or pulled out as needed, and monitor urine color, odor, and sediments (solid material that settles at the bottom of a liquid) every shift.
During a concurrent observation and interview with Certified Nursing Assistant 1 (CNA 1) on 2/1/2024 at 10:02 a.m. inside Resident 2 ' s room, observed CNA 1 holding Resident 2 ' s urinary bag while transferring Resident 2 from the wheelchair to the shower chair. Observed CNA 1 place Resident 2 ' s urine bag above the Resident 2 ' s bladder while assisting the resident to transfer from the wheelchair to the shower chair. When CNA 1 was asked where Resident 2 ' s urine bag should placement while transferring a resident, CNA 1 stated that it should be placed below the resident ' s bladder at all times including while a resident transferring. CNA 1 stated that he did not realize that he placed the urine bag above Resident 2 ' s bladder while transferring the resident between wheelchair and shower chair.
During an interview with the Director of Staff Developer (DSD) on 2/1/2024 at 10:50 a.m., DSD stated that CNA 1 should have placed Resident 2 ' s urine bag to the lower part of the shower chair first, before attempting to transfer the resident from wheelchair to shower chair. DSD stated that a resident ' s urine bag should be placed at a lower level than a resident ' s bladder at all times, otherwise germs could go up into the resident urinary tracts of a resident placed them at high risk for urinary tract infections.
A review of the facility ' s policy and procedures (P&P) titled, Indwelling Catheter Care reviewed 03/2021 and last review on 8/17/2023, indicated, The catheter and tubing must remain patent [not clogged], with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pulling and back flow of urine into the bladder. The drainage bag should be kept off the floor.
Nov 2023
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote the resident's right to be informed of by the physician of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote the resident's right to be informed of by the physician of the risks and benefits of the proposed plan for the administration of a psychotropic medication (medication that affects brain activities to control behavior or treat disordered thought processes) Olanzapine (a medication used to treat schizophrenia [a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior] and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) for one of two sampled residents (Resident 62).
This deficient practice had the potential for the resident and / or the resident 's representative (RR) not to be well-informed of the medications and the potential risks and side effects (undesirable effect of a medication or treatment). This also had the potential to place the resident and the RR to miss the opportunity to decide whether to proceed or to refuse the medication.
Findings:
A review of Resident 62's Face Sheet (admission Record) indicated that the facility originally admitted the resident on 06/30/2023 and readmitted on [DATE], with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and gastro-esophageal reflux disease (GERD- a common condition in which the stomach contents move up into the esophagus [a hollow muscular tube that connects the back of the throat to the top of the stomach]).
A review of Resident 62`s History and Physical (H&P- a term used to describe a physician's examination of a resident) dated 09/21/2023 indicated that the resident has fluctuating (to shift or change back and forth uncertainly) capacity to understand and make decisions.
A review of Resident 62's Physician`s Order dated 10/27/2023, included Olanzapine oral tablet 2.5 milligrams (mg- unit of measure), one (1) tablet by mouth in the morning and five (5) mg by mouth at bedtime for dementia manifested by angry outburst.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 11/02/2023 at 3:52 p.m., Resident 62`s Informed Consent Form,, undated, was reviewed. The ADON stated Resident 62's Informed Consent form did not have Resident 62 physician's signature and did not indicate the date when the Informed Consent form was completed. The ADON stated that it is a requirement for any psychotropic medication order to obtain the resident`s or RR's consent with the physician's signature who obtained the consent. The ADON stated that it is the right of the resident to know what medication they are taking and to be informed of risk and benefits of the medications and any side effects or adverse effects (an undesired harmful effect resulting from a medication). The ADON further stated it is a violation of a resident's right not to be informed especially for psychotropic medication.
A review of the facility`s policy and procedure titled Informed Consent, last reviewed on 8/17/2023, indicated that It is the policy of the facility that if the attending physician, physician assistant (PA), or nurse practitioner (NP) of a resident prescribes, orders, or increases an order for a psychotherapeutic [relating to or denoting the treatment of mental conditions] medication .the physician, PA or NP shall obtain the informed consent of the resident for purposes of prescribing, ordering or increasing an order for a medication, .seek the consent of the resident`s responsible party, if the resident is not competent to make treatment decisions as designated in the medical record .
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 the low air loss mattress (LAL- mattress designed to prevent and treat pressure wounds [injury to skin and underlying t...
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Based on observation, interview and record review, the facility failed to ensure the low air loss mattress (LAL- mattress designed to prevent and treat pressure wounds [injury to skin and underlying tissue resulting from prolonged pressure on the skin]) was on the needed setting per manufacturer's guidelines for one of two sampled residents (Resident 34).
This failure had the potential to place Resident 34 at risk for developing or worsening pressure wounds.
Findings:
A review of Resident 34's admission Record indicated the facility admitted the resident on 9/16/2023 with diagnosis that included sepsis (a serious condition in which the body responds improperly to an infection), urinary tract infection (infection in any part of the urinary system), and pneumonia (infection that affects one or both lungs).
A review of Resident 34's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/23/2023, indicated Resident 34's cognition (a mental process of acquiring knowledge and understanding) was intact.
A review of Resident 34's Physician's Order dated 9/18/2023 indicated an order for a low air loss (LAL) mattress for wound management.
During an observation on 11/01/2023 at 1:36 p.m., observed Resident 34 on LAL mattress. Observed LAL setting at 180 (indicating the resident's weight in pounds [lbs.- unit of measure]).
During an observation on 11/02/2023 at 9:02 a.m., observed Resident 34 on LAL mattress. Observed LAL setting at 180.
During a concurrent observation and concurrent interview with Licensed Vocational Nurse 4 (LVN 4) on 11/02/2023 at 5:05 p.m., observed Resident 34's LAL mattress setting. LVN 4 stated that Resident 34's LAL mattress is set to 180.
During an interview and concurrent record review with Treatment Nurse (TN) on 11/3/2023 at 1:29 p.m., Resident 34 weight log was reviewed. TN stated that according to Resident 34's weight log, Resident 34's current weight as of 10/16/2023 was 137 lbs. TN stated that Resident 34's LAL mattress is used for wound management. When asked how the facility ensures that the LAL mattress is at the proper setting, TN stated that the facility will physically check the bed by applying pressure onto the mattress and will set the knob based on the weight of the resident. TN stated that Resident 34's LAL mattress should be set closer to 140. TN stated that the correct LAL mattress setting is important for wound management because if it is not at the correct setting, it may affect wound healing.
A review of the facility provided manufacturer's guidance for the Med-Aire Melody Alternating Pressure Low Air Loss Mattress replacement system, dated 3/22/2021, indicated to determine the patient's weight and set the control knob to that weight setting on the control unit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident's physician's orders were followed by failing to flush a resident's gastrostomy tube (G-Tube - a tube inser...
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Based on observation, interview, and record review, the facility failed to ensure a resident's physician's orders were followed by failing to flush a resident's gastrostomy tube (G-Tube - a tube inserted through the abdomen that brings nutrition and medications directly to the stomach) with water in between each medication administration for one of two sampled residents (Resident 41) observed during the medication administration task.
This failure had the potential for drug interaction with unknown side effects and for the G-tube to become clogged.
Findings:
A review of Resident 41's Face Sheet (admission record) indicated the facility admitted the resident on 9/02/2023 with diagnoses that included hypertension (HTN - high blood pressure, normal reference range is 120/80 millimeters of Mercury [mmHg - unit of measure]), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it; stroke), and benign prostatic hyperplasia (BPH- enlarged prostate [gland found in males]),
A review of Resident 41' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/08/2023, indicated Resident 41 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) skills required for daily decision making. The MDS indicated Resident 41 required extensive assistance from staff with bed mobility, dressing and personal hygiene. The MDS indicated Resident 41 had the presence of a G-Tube.
A review of Resident 41's Physician's Orders indicated the following:
1. Flush G-Tube with 10 cubic centimeters (cc- a unit of measure for liquid) of water between each medication every shift, dated 10/03/2023.
2. Amlodipine tablet (a medication to treat HTN and chest pain)- Give 7.5 milligrams (mg - a unit of measure) by G-Tube one time a day for hypertension, hold for systolic blood pressure (SBP - the top number of the blood pressure reading, measures the pressure in the arteries when the heart beats) less than 110 mmHg, dated 10/03/2023.
3. Aspirin (a medication used to treat pain, fever and swelling) 81 mg - Give one tablet by G-Tube one time a day for stroke prophylaxis (a medication given to prevent a condition from occurring), dated 9/02/2023.
4. Atenolol (a medication used to treat angina [chest pain] and high blood pressure) tablet 25 mg - Give one tablet by G-Tube one time a day for HTN, hold if SBP is less than 110 mmHg or if heart rate is less than 60 beats per minute (bpm - beats per minute, normal reference range 60 to 100 bpm.), dated 9/02/2023.
5. Cholecalciferol tablet (Vitamin D3 supplement) tablet 1000 units - Give one tablet by G-Tube one time a day for supplement, dated 9/02/2023.
6. Finasteride (a medication used to treat BPH) tablet five (5) mg - Give one tablet by G-Tube one time a day for BPH, handle with mask and gloves, dated 9/26/2023.
7. Losartan (a medication used to treat high blood pressure and heart failure) 50 mg tablet - Give one tablet by G-Tube two times a day for HTN, hold if SBP is less than 110mmHg, dated 10/11/2023.
8. Multiple Vitamins-Mineral Tablet - Give one tablet by G-Tube one time a day for supplement, dated 9/12/2023.
A review of Resident 41's Care Plan for Tube Feeding, initiated 9/18/2023, indicated a goal that Resident 41 will tolerate feeding without emesis (throwing up), aspiration (inhaling feeding into the lungs), or diarrhea (loose bowel movements) daily for 90 days. The care plan indicated an intervention to flush the G-Tube with water as ordered.
During a medication pass observation with Licensed Vocational Nurse 2 (LVN 2) on 10/31/2023 at 8:57 a.m., observed the 9:00 a.m. medication pass for Resident 41. Observe LVN 2 place each of the seven (7) prepared medications (Multiple Vitamin and Mineral, Losartan, Finasteride, Cholecalciferol, Atenolol, Aspirin, and Amlodipine) for Resident 41in a separate medication cup (small clear up used during preparation of a resident's medication) and mixed each medication in the medication cup with water. Observed LVN 2 then poured the first cup of medication mixed with water into Resident 41's G-Tube. LVN 2 then poured additional water to mix with the medication residue left in the medication cup after which LVN 2 then administering the water with remaining medication residue to Resident 41. Observed LVN 2 then proceed to do this for each of the six remaining medications due for administration.
During an interview with LVN 2 on 10/31/2023 at 9:30 a.m., when asked why LVN 2 did not flush the G-Tube with exactly 10 cc water from a separate cup in between giving each medication to Resident 41, LVN 2 stated she did not want Resident 41 to receive too much water. LVN 2 stated she should have followed the physician's order of providing Resident 41 with 10 cc of water in between each medication.
During an interview with the Director of Nurses (DON) on 11/03/2023 at 8:48 a.m., DON stated that LVN 2 should have followed Resident 41's physician's order to flush the G-tube with 10cc of water in between each medication during medication administration. The DON stated this is important because the water in between medications will help avoid having the medications mixing with another medication and to avoid clogging of the G-Tube.
A review of the facility's policy and procedure titled, Documentation Medication Administration-General Guidelines, last reviewed on 08/17/2023, indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the attending physician.
A review of the facility's policy and procedure titled, Gastrostomy Tube Feeding via Continuous Pump, last reviewed on 8/17/2023, indicated it is the policy of the facility to provide nourishment via continuous pump to residents who are unable to obtain adequate nourishment orally, as ordered by the resident's attending physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the facility's Pharmacy Consultant (PC) conduct a Drug Regimen Review (DRR- a review of the drug regimen of a resident to identify a...
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Based on interview and record review, the facility failed to ensure the facility's Pharmacy Consultant (PC) conduct a Drug Regimen Review (DRR- a review of the drug regimen of a resident to identify and, if possible, prevent clinically significant medication issues) for the month of October 2023 for one of two sampled residents (Resident 9) investigated under unnecessary medications review.
This deficient practice has the potential to miss the identification of any medication irregularities which could lead to the resident receiving an unnecessary medication with adverse side effects (unwanted undesirable effects that are possibly related to a drug).
Findings:
A review of Resident 9`s Face Sheet (admission Record) indicated the facility originally admitted the resident on 12/16/2022 and readmitted the resident on 06/17/2023, with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) and diabetes mellitus (the body's inability to regulate the amount of sugar).
A review of Resident 9's Minimum Data Set (MDS - an assessment and care screening tool), dated 09/22/2023, indicated the resident's cognitive (cognition refers to conscious mental activities that include thinking, reasoning, understanding, learning, and remembering) skills for daily decision-making was intact. The MDS further indicated Resident 9 required extensive assistance from staff for activities of daily living (are essential and routine tasks that most young, healthy individuals can perform without assistance).
During a concurrent interview and record review with the Assistant Director of Nursing (ADON), reviewed Resident 9's DRR and noted that there was no DRR done for 10/2023. The ADON stated that a DRR is done monthly for residents in order to identify any irregularities in the resident's medication regime, and if there are any special consideration that needs to be considered such as if medication needs to be crushed, be given with food, or if the dose is appropriate for the resident. The ADON stated that if DRR is not conducted, the resident may have the potential to receive unnecessary medication that could result to adverse side effects.
A review of the facility`s policy and procedure titled Drug Regimen Review, last reviewed on 8/17/2023, indicated that It is the policy of the facility that each resident`s drug regimen be reviewed by the Pharmacy Consultant monthly .each monthly drug regimen review must include a review of the resident`s medical record .if the Pharmacy Consultant identifies an irregularity that requires urgent action to prevent harm, the licensed nurse will call the physician to report the irregularity and will write a progress note and/or telephone order with the physician`s recommendation and/or order .
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 label and store drugs (medications) and biologicals (a therapeutic substance such as drugs that target specific parts of your...
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Based on observation, interview, and record review, the facility failed to label and store drugs (medications) and biologicals (a therapeutic substance such as drugs that target specific parts of your immune system to treat disease) in accordance with accepted professional principles as evidenced by:
1. Failure to ensure a bottle of Valproic Acid Oral Solution (a medication used to treat bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration] or to prevent one from having a seizure [sudden, uncontrolled burst of electrical activity in brain that can cause changes in behavior, movements, feelings and levels of consciousness]) had the date it was opened documented on the bottle.
2. Failing to ensure a bottle of Iron (an important mineral that the body needs to produce red blood cells [delivers oxygen to tissues in your body] and keep an individual in good health) supplement was left in the medication cart past its expiration date of 1/2023.
These deficient practices had the potential for residents to receive medication that had become ineffective or toxic due to improper labeling and using the medication after its expired date.
Findings:
During a medication cart observation and inspection with Licensed Vocational Nurse 4 (LVN 4) on 10/30/2023 at 5:00 p.m., observed the Red Zone (the area designated for those residents who have active Corona Virus Disease 2019 [Covid-19- a respiratory virus that cause difficulty breathing, hospitalization, and possibly death]) Medication Cart. Observed in the Red Zone medication cart was a bottle of Valproic Acid Oral Solution 250 milligrams per five (5) milliliters (mg/ml- unit of measure) bottle with no open date (when staff write the date the medication is opened on the container). Also observed was a bottle of Iron supplement with an expiration date of 1/2023. LVN 4 stated that for any liquid medications, facility staff should always write an open date on the bottle when first used as medications can lose their effectiveness over a period of time once opened. LVN 4 stated that medications should be discarded once the expired date is met because expired medications also lose their effectiveness.
A review of the facility's policy and procedure titled Medication Storage in the Facility, last reviewed on 8/17/2023 indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated medications are immediately removed, disposed of according to procedures for medication disposal and re-ordered from the pharmacy if a current order exists. Medication storage conditions are monitored on a routine basis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 179's admission Record indicated the facility admitted the resident on 10/21/2023 with diagnoses includi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 179's admission Record indicated the facility admitted the resident on 10/21/2023 with diagnoses including Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), chronic kidney disease (involves a gradual loss of kidney function) and pneumonia (an infection that affects one or both lungs).
A review of Resident 179`s History and Physical (H&P- a term used to describe a physician's examination of a resident) dated 10/23/2023 indicated that the resident has the capacity to understand and make decisions.
A review of Resident 179`s Physician`s Order dated 10/23/2023, included an order for Oxygen at three (3) liters per minute (LPM - unit of measure) via nasal cannula as needed to keep oxygen saturation (the amount of oxygen that's circulating in your blood) level above 90 percent (%- unit of measure).
A review of Resident 179's Care Plan dated 10/23/2023 indicated the resident have the potential for shortness of breath and requires use of oxygen as needed. The Care Plan included interventions to change tubing every week.
During a concurrent observation and interview with Director of Staff Development (DSD) on 10/30/2023 at 9:17 a.m., observed Resident 179 sleeping and with the oxygen concentrator (a medical device that gives you extra oxygen) turned on. Also observed was a part of Resident 179`s nasal cannula tubing that was touching the floor. The nasal cannula did not have a date to indicate when it was first used which serves as a basis of when to change the nasal cannula tubing. The DSD stated that oxygen tubing is to be changed every week to prevent tubing from contamination. The DSD stated that nasal cannula tubing should not be touching the floor because it might get contaminated and may introduce an infectious microorganism to the resident which can lead to infection.
A review of the Centers for Disease Control (CDC) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, 2003, indicated floors can become rapidly re-contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances.a
Based on observation, interview, and record review, the facility failed to:
1. Ensure the peripheral intravenous (IV, a medical technique that administers fluids and medications directly into a person's vein) access (the insertion of a flexible and sterile thin plastic tube, or catheter, into a blood vessel to provide medication) dressing was labeled with the insertion date for one of three sampled residents (Resident 132) observed with IV access.
2. Implement infection control practices for one of two sampled residents (Resident 179) by failing to ensure the resident's nasal cannula (a medical device that delivers extra oxygen through a tube and into your nose) tubing was dated to indicate the date it was last changed and that the tubing was not touching the floor.
These deficient practices had the potential to transmit infectious microorganisms (germs that have the potential to cause disease) and placed the resident at risk for infection.
Findings:
1. A review of Resident 132's Face Sheet (admission Record) indicated the facility admitted the resident on 10/17/2023 and re-admitted on [DATE], with diagnoses that included left lower limb (lower leg) cellulitis (a common, potentially serious bacterial skin infection in which the affected skin is swollen and inflamed).
A review of Resident 132's Minimum Data Set (MDS - an assessment and care screening tool), dated 10/23/2023, indicated Resident 132 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 132 required setup assistance (helper sets up and resident completes the activity) with eating and personal hygiene.
A review of Resident 132's IV Therapy Care Plan, initiated 10/17/2023, indicated Resident 132 needs IV therapy for an antibiotic medication (a medication given to fight a bacterial infection). The care plan indicated a goal that cellulitis of the left leg will be resolved after completion of IV therapy.
During a concurrent interview and observation with Registered Nurse 1 (RN 1), on 10/30/2023 at 10:41 a.m., observed Resident 132's right wrist IV access dressing without a label to indicate the date it was inserted and by whom. RN 1 stated that Resident 132's right wrist IV access did not have a label on the dressing to indicate when it was placed. RN 1 stated that resident peripheral IV access lines are only to be kept in place for three days.
During a follow up interview with RN 1 on 10/31/2023 at 2:38 p.m., RN 1 stated that she had been informed by the Director of Nurses (DON) that Resident 132's right wrist IV access has been in place since the resident returned from the General Acute Care Hospital (GACH) on 10/24/2023.
During an interview with the DON on 10/31/2023 at 3:00 p.m., the DON stated that it is important to know when an IV is inserted because if it is kept for longer than three days, a resident could be at risk for an infection.
During an interview with Registered Nurse 2 (RN 2) on 10/31/2023 at 3:50 p.m. RN 2 stated she was notified by the DON on 10/25/2023 of Resident 132's right wrist IV access but forgot to notify Resident 132's physician to obtain an order whether to continue the use of Resident 132's peripheral IV access site from the GACH or to discontinue the peripheral IV access site. RN 2 stated she should have notified Resident 132's physician because the resident could be at risk for infection if the right wrist IV access line is kept in place for a long time and without knowing the insertion date.
A review of the facility's policy and procedure titled, Insertion of Peripheral IV Catheter, last reviewed by the facility on 8/17/2023, indicated that peripheral IV devices will be rotated routinely every 72 hours. The policy indicated IV catheters in residents with limited peripheral venous access may be maintained for a maximum of seven days, with a physician's order.
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 the hemodialysis (also known as dialysis, the process of removing waste products and excess fluid from the body because the kidneys ...
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Based on interview and record review, the facility failed to ensure the hemodialysis (also known as dialysis, the process of removing waste products and excess fluid from the body because the kidneys no longer function) center documented the pre (before) and post (after) dialysis weight of one of two sampled resident (Resident 279).
This deficient practice placed the resident at risk for potential unidentified complications after dialysis treatment.
Findings:
A review of Resident 279' s Face Sheet (admission Record) indicated the facility admitted the resident on 9/25/2023 with diagnoses that included 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) and dependence on renal (kidney) dialysis.
A review of Resident 279's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/09/2023, indicated Resident 279 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 279 required moderate assistance (helper does less than half the effort) from staff with bed mobility, dressing, eating and personal hygiene.
A review of Resident 279's Physician's Orders, dated 10/12/2023, indicated an order for Resident 279 to have hemodialysis done every Monday, Wednesday, and Friday.
A review of Resident 279's Dialysis Unit Progress Records indicated the following:
1. 9/27/2023 no pre-dialysis weight and no post-dialysis weight
2. 10/06/2023 no post-dialysis weight
3. 10/09/2023 no post-dialysis weight
4. 10/13/2023 no pre-dialysis weight and no post-dialysis weight
5. 10/18/2023 no post-dialysis weight
6. 10/20/2023 no post-dialysis weight
7. 10/23/2023 no pre-dialysis weight and no post-dialysis weight
During a concurrent interview and record review on 11/03/2023 at 12:59 p.m., reviewed Resident 279's Dialysis Unit Progress Records from 9/27/23 to 10/23/23 with Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 3 (LVN 3). RN 1 and LVN 3 stated that for Resident 279, the dialysis center did not document the pre-dialysis and post-dialysis weights on 9/27/2023, 10/13/2023, and 10/23/2023. RN 1 and LVN 3 stated there were no post-dialysis weights documented by the dialysis center for Resident 279 on 10/06/2023, 10/09/2023, 10/18/2023, and 10/20/2023. RN 1 and LVN 3 stated the dialysis center should have documented the pre and post weight of Resident 279 after each dialysis treatment. RN 1 and LVN 3 stated the importance of having these weights is to know how much fluid weight had been removed from the resident. RN 1 and LVN 3 stated if there was a great amount of fluid removed, it could result in abnormal vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a resident's essential body functions) such as hypotension (low blood pressure) and dizziness.
During a concurrent records review and interview with the Director of Nurses (DON) on 11/03/2023 at 1:17 p.m., reviewed Resident 279's Dialysis Unit Progress Records from 9/27/23 to 10/23/23 with the DON. The DON stated the pre-dialysis and post-dialysis weights should be documented by the dialysis center. The DON stated this was important so that licensed nurses would be aware if there was a large amount removed and expect to see such negative side effects (undesirable effect of a medical treatment).
A review of the facility's policy and procedure titled, Dialysis Care, reviewed 8/17/2023, indicated the Post Dialysis Checklist will accompany the resident to dialysis and the dialysis unit will complete with the required information including pre-dialysis and post-dialysis weights.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure:
1. Licensed nurses signed one of three sampled resident's (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure:
1. Licensed nurses signed one of three sampled resident's (Resident 14) Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) after administering Hydrocodone-Acetaminophen (Norco- a medication used to treat pain) to the resident on six separate occasions.
2. Licensed nurses signed one of three sampled resident's (Resident 34) MAR after administering Norco to the resident on 10/4/2023.
3. Licensed nurses signed one of three sampled resident's (Resident 24) MAR after administering Acetaminophen-Codeine Number 3 (Tylenol #3 - a medication used to treat pain) to the resident on 10/22/2023 and 10/29/2023.
4. Physician`s order to check for blood sugar and to administer Insulin Lispro (a medication used to control high blood sugar) are implemented on 10/24/2023 for one of one resident (Resident 40) investigated under quality of care.
5. Licensed nurses immediately signed one of one sampled resident's (Resident 59) MAR after administering or attempting to administer Diclofenac Sodium External Gel (medication used to relieve pain from arthritis [swelling of the joints] in certain joints such as those of the knees, ankles, feet, elbows, wrists, and hands) to the resident on 12 occasions on 10/2023.
These deficient practices had the potential to result in medication errors, increased risk for the potential drug loss, diversion (transfer of a medication from a legal to an illegal use) and had the potential to result in confusion on the delivery of care and services.
Findings:
1. A review of Resident 14's admission Record indicated the facility readmitted the resident on 03/19/203 with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection), pneumonia (an infection that affects one or both lungs) and type two [2] diabetes (a chronic condition that occurs because of a problem in the way the body regulates and uses sugar as a fuel or source of energy, blood sugar is too high).
A review of Resident 14's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/19/2023, indicated Resident 14's cognition (a mental process of acquiring knowledge and understanding) was intact.
A review of Resident 14's Physician's Order indicated the following orders:
a. Norco oral tablet 5/325 milligrams (mg- unit of measure). Give one (1) tablet by mouth one time a day for pain management hold if respiration rate (RR) are less than 12 or if resident is lethargic (feeling drowsy, unusually tired, not alert); give at 11:00 a.m. per resident's request, dated 10/05/2023.
b. Norco oral Tablet 5/325 mg. Give one (1) tablet by mouth every six (6) hours as needed for moderate to severe pain (pain rated at four [4] or higher out of 10, on a pain scale from zero to ten where ten is the worst possible pain), dated 03/31/2023.
During an interview and concurrent record review with Licensed Vocational Nurse 2 (LVN 2) on 11/02/2023 at 12:03 p.m., Resident 14's MAR and Control Drug Record for Norco 5/325 mg for 10/2023 were reviewed. LVN 2 stated that when preparing to administer a controlled medication (medications that can cause physical and mental dependence, wherein use and distribution are tightly controlled because of their abuse potential) licensed nurses will prepare the medication for the resident, administer the medication to the resident, sign the resident's MAR indicating that the controlled medication was administered to the resident, and then sign the resident's Controlled Drug Count Sheet (or Controlled Drug Record, a document to ensure all controlled medications are accounted for) so that there is an accurate accounting of the usage of the controlled medication. LVN 2 further stated that the importance of the Controlled Drug Record (a document to ensure all controlled medications are accounted for) is to keep a count of the controlled drug for a resident and for accountability by showing who was responsible for each dose of an administered controlled medication. LVN 2 stated that according to Resident 14's MAR and controlled drug record for Norco for 10/2023, the following was noted:
a. The Controlled Drug Record showed that a dose of Norco 5/325 mg was removed on 10/21/2023 at 6:00 a.m., but there was no documented evidence that Norco 5/325mg was administered to Resident 14 on 10/21/2023 at 6:00 a.m. in the resident's MAR.
b. The Controlled Drug Record showed that a dose of Norco 5/325 mg was removed on 10/22/2023 at 6:00 p.m., but there was no documented evidence that Norco 5/325mg was administered to Resident 14 on 10/22/2023 at 6:00 p.m. in the resident's MAR.
c. The Controlled Drug Record showed that a dose of Norco 5/325 mg was removed on 10/22/2023 at 11:00 a.m., but there was no documented evidence that Norco 5/325mg was administered to Resident 14 on 10/22/2023 at 11:00 a.m. in the resident's MAR.
d. The Controlled Drug Record showed that a dose of Norco 5/325 mg was removed on 10/26/2023 at 9:00 p.m., but there was no documented evidence that Norco 5/325mg was administered to Resident 14 on 10/26/2023 at 9:00 p.m. in the resident's MAR.
e. The Controlled Drug Record showed that a dose of Norco 5/325 mg was removed on 10/27/2023 at 11:00 a.m., but there was no documented evidence that Norco 5/325mg was administered to Resident 14 on 10/27/2023 at 11:00 a.m. in the resident's MAR.
f. The controlled drug record showed that a dose of Norco 5/325 mg was removed on 10/29/2023 at 8:00 a.m., but there was no documented evidence that Norco 5/325mg was administered to Resident 14 on 10/29/2023 at 8:00 a.m. in the resident's MAR.
2. A review of Resident 34's admission Record indicated the facility admitted the resident on 9/16/2023 with diagnoses that included, urinary tract infection (infection in any part of the urinary system), and pneumonia.
A review of Resident 34's MDS dated [DATE], indicated Resident 34's cognition was intact.
A review of Resident 34's Order Summary Report indicated an order for Norco oral tablet 5-325mg. Give one (1) tablet by mouth every six (6) hours as needed for moderate to severe pain, with a start date of 09/25/2023.
During a concurrent interview and record review with LVN 2 on 11/02/2023 at 12:18 p.m., Resident 34's MAR and Controlled Drug Record for Norco 5/325 mg for 10/2023 were reviewed. LVN 2 stated that Resident 34's Controlled Drug Record showed that a dose of Norco 5/325 mg was removed on 10/04/2023 at 7:45 p.m., but there was no documented evidence that Norco 5/325 mg was administered to Resident 34 on 10/4/2023 at 7:45 p.m. in the resident's MAR.
3. A review of Resident 24's admission Record indicated the facility admitted the resident on 03/10/2023 with diagnoses that included difficulty in walking, muscle weakness, and primary osteoarthritis (occurs when flexible tissue at the ends of bones wears down).
A review of Resident 24's MDS dated [DATE], indicated Resident 24's cognition was moderately impaired.
A review of Resident 24's Order Summary Report indicated Acetaminophen-Codeine #3 (Tylenol #3) oral Tablet 300-30 mg. Give one (1) tablet by mouth every six (6) hours as needed for moderate to severe pain.
During a concurrent interview and record review with LVN 2 on 11/02/2023 at 12:19 p.m., Resident 24's MAR and Controlled Drug Record for Acetaminophen-Codeine #3 for 10/2023 were reviewed.
The Controlled Drug Record showed that a dose of Acetaminophen-Codeine #3 300-30 mg was removed on 10/22/2023 at 9:00 a.m., but there was no documented evidence that Acetaminophen-Codeine #3 300-30 mg was administered to Resident 24 on 10/22/2023 at 9:00 a.m. in the resident's MAR.
a. The controlled drug record showed that a dose of Acetaminophen-Codeine #3 300-30 mg was removed on 10/29/2023 at 8:00 a.m., but there was no documented evidence that Acetaminophen-Codeine #3 300-30 mg was administered to Resident 24 on 10/29/2023 at 8:00 a.m. in the resident's MAR.
A review of the facility's policy and procedure titled, Medication Administration- General Guidelines, reviewed on 08/17/2023, indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented.
4. A review of Resident 40`s Face Sheet (admission Record) indicated the facility originally admitted the resident on 06/02/2022 and readmitted the resident on 06/06/2023, with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and diabetes mellitus (DM-a group of diseases that affect how the body uses sugar [glucose], results in too much sugar in the blood).
A review of Resident 40's MDS, dated [DATE], indicated the resident's cognitive skills for daily decision-making was intact. The MDS further indicated Resident 40 required extensive assistance from staff for activities of daily living (are essential and routine tasks that most young, healthy individuals can perform without assistance).
A review of Resident 40`s Physician`s Order dated 10/23/2023, included Admelog Solostar Solution Pen-Injector (a disposable single-resident-use prefilled insulin [medication that helps lower sugar level in the body] pen) 100 Unit/milliliter (U/ml- unit of measure) Insulin Lispro (fast acting insulin) inject 12 units subcutaneously (under the skin) before meals for DM and call physician if blood sugar is less than 70 milligram/deciliter (mg/dl- unit of measure) or over 250 mg/dl.
During a concurrent interview and record on 11/02/23 09:24 a.m. with the Assistant Director of Nursing (ADON), reviewed Resident 40`s Medication Administration Record (MAR) for 10/2023. The ADON stated the following after reviewing Resident 40's MAR for 10/2023:
a. On 10/24/2023 at 6:50 a.m. there was no documented evidence that the licensed nurse obtained Resident 40's blood sugar level and there was no documented evidence if Lispro was administered to the resident.
b. On 10/24/2023 at 4:50 p.m. there was no documented evidence that the licensed nurse obtained Resident 40's bloods sugar level and there was no documented evidence if Lispro was administered to the resident.
The ADON stated that if blood sugars are not monitored and obtained per physician's order prior to administration of an insulin, the resident would be at risk for either hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar). The ADON stated that if the resident`s blood sugar is high, he or she could be having blurry vision which could result in a fall and possibly injury; if the blood sugar is low, the resident could have a seizure (uncontrolled stiffness, twitching or limpness) which can lead to injury.
A review of the facility`s policy and procedure titled Diabetic Care, last reviewed on 8/17/2023, indicated that It is the policy of this facility to have a standardization of diabetic care through nutritional support, blood glucose testing and appropriate interventions and assessments for diabetic complications .Provide blood glucose monitoring as ordered by the physician.
5. A review of Resident 59's admission Record indicated the facility admitted the resident on 07/23/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and venous insufficiency (a condition in which veins have problems moving blood back to the heart).
A review of Resident 59's MDS dated [DATE] indicated the resident has the capacity to make self-understood and has the capacity to understand others.
A review of Resident 59's Physician's Orders indicated an order for Diclofenac Sodium External Gel (medication used to relieve pain from arthritis [swelling of the joints] in certain joints such as those of the knees, ankles, feet, elbows, wrists, and hands) one (1) percent (%- unit of measure), apply to bilateral (right and left) hands and wrists topically (applied to a body surface, including the skin) every 12 hours for pain management for 30 days, apply two [2] Grams (GM- unit of measure).
A review of Resident 59`s Care Plan dated 10/12/2023, indicated that Resident 59 has a problem of chronic pain due to diagnosis of neuropathy (happens when the nerves that are located outside of the brain and spinal cord are damaged) with a care plan goal of pain to be controlled with lowest possible side effects. The care plan included an intervention for medications to be administered per physician`s order.
On 10/30/2023 at 9:37 a.m., during a concurrent observation and interview, observed Resident 59 in bed, covered with blanket up to her neck. Resident 59 stated that she does not want to move her arms because it is painful if she moves it. When asked if she had taken any pain medications, Resident 59 responded that she cannot remember if she was given any pain medication today.
During a concurrent interview and record review on 11/02/2023 at 2:04 p.m., with the ADON, Resident 59`s MAR and Administration History (AH- reflects the actual time the licensed nurse documented on a resident's MAR) for 10/2023 were reviewed. The ADON stated that Resident 59's MAR indicated the time of administration for Diclofenac at 9:00 a.m. and 9:00 p.m. The ADON stated after reviewing Resident 59's MAR for 10/2023 and Resident 59's AH for 10/2023, that the licensed nurses were not documenting the administration of Resident 59's Diclofenac immediately after providing the resident with the medication. DON stated that Resident 59's MAR and AH for 10/2023 indicated the following:
Medication Administration Record Administration History
10/20/23 9:00 a.m. Documented at 05:35 p.m.
10/21/23 9:00 a.m. (refused) Documented at 05:44 p.m.
10/22/23 9:00 a.m. Documented at 05:01 p.m.
10/23/23 9:00 a.m. (refused) Documented at 05:52 p.m.
10/24/23 9:00 a.m. Documented at 12:07 p.m.
10/25/23 9:00 a.m. Documented at 04:38 p.m.
10/26/23 9:00 a.m. Documented at 11:26 p.m.
10/27/23 9:00 a.m. Documented at 05:49 p.m.
10/28/23 9:00 a.m. Documented at 04:03 p.m.
10/29/23 9:00 a.m. Documented at 05:56 p.m.
10/30/23 9:00 a.m. Documented at 10:39 a.m.
10/31/23 9:00 a.m. Documented at 05:47 a.m.
The ADON stated that nurses` should have followed the policy and procedure which instructs them to provide the medication to the resident and then sign accordingly.
The ADON stated that if Diclofenac is not given on time it could result to the resident to be in pain when it could have been alleviated if the pain medication is given on time.
A review of the facility`s policy and procedure titled Medication Administration Guidelines, last reviewed on 8/17/2023, indicated that the individual who administers the medication dose records the administration on the resident`s MAR directly after the medication is given.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 54's admission Record indicated the facility readmitted the resident on 03/07/2023, with diagnosis that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 54's admission Record indicated the facility readmitted the resident on 03/07/2023, with diagnosis that included bipolar disorder.
A review of Resident 54's MDS, dated [DATE], indicated the resident has the capacity to make self-understood and the capacity to understand others.
A review of Resident 54's Order summary indicated the following:
a. Abilify Tablet 15 mg. Give one (1) tablet by mouth at bedtime for bipolar disorder manifested by mood swings as evidenced by persistent fluctuation of depressive (a persistent feeling of sadness and loss of interest) and manic (a state of mind characterized by high energy, excitement, and euphoria [feeling or state of intense excitement and happiness] behavior. Order date: 12/05/2022
b. Depakote tablet delayed release (released over a period of time) 500 mg. Give three (3) tablets by mouth at bedtime for bipolar disorder manifested by mood swings as evidenced by angry outburst for no apparent reason. Order date: 9/28/2023
c. Lithium Carbonate tablet 300 mg. Give 2.5 mg tablet by mouth one time a day for bipolar disorder manifested by appears on edge as evidenced by angry outburst. Order date: 12/27/2022
During an interview with Licensed Vocational Nurse 4 (LVN 4) on 11/03/2023 at 1:26 pm, LVN 4 stated that Resident 54 has medication orders for his diagnosis of bipolar disorder. When asked what specific behaviors Resident 54 was being monitored for, LVN 4 stated there were no specific behaviors that were being monitored. LVN 4 stated that the behaviors are general and not specific.
During an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 11/03/2023 at 2:17 p.m., the ADON stated that there are no specific behaviors being monitored for Resident 54's orders of Abilify, Lithium, and Depakote. The ADON continued to state that the medications ordered should have a specific target behavior monitored so that staff will know what to monitor. The ADON stated that monitoring the increase or decrease in behaviors will assist the medical doctor or psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) in determining the appropriate dosage of the medication of the resident.
A review of the facility's policy and procedure titled, Psychotropic (medications that affect the mind, emotions and behavior) Drug Treatment, reviewed 8/17/2023, indicated psychotropic drugs are to be used for a resident with a specific condition as diagnosed and documented in the clinical record. The policy and procedure indicated, before initiated an antipsychotic medication, the target behavior must be clearly and specifically identified and documented.
Based on observation, interview and record review, the facility failed to ensure:
1. Licensed nurses monitored the behavior of angry outburst for a resident on Olanzapine (a medication used to treat schizophrenia [a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior] and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) for one of five sampled residents (Resident 74) investigated for unnecessary medications.
2. Licensed nurses were monitoring specific behaviors of one of two sampled residents (Resident 54) for the use of Abilify (a medication used to treat schizophrenia and bipolar disorder by regulating mood, behavior, and thoughts), Lithium Carbonate (a mood stabilizing medicine used to treat bipolar disorder), Depakote (used to treat bipolar disorder).
This deficient practice had the potential to result in adverse reaction or impairment in the resident's mental or physical condition.
Findings:
1. A review of Resident 74's admission Record indicated the facility admitted the resident on 7/15/2023, with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disorder (a mental health condition that primarily affects your emotional state).
A review of Resident 74's Minimum Data Set (MDS - an assessment and care screening tool), dated 10/08/2023, indicated Resident 74 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 74 required moderate assistance (helper does less than half the effort) from staff with eating, and transfer from bed to wheelchair.
A review of Resident 74's Physician's Orders indicated the following:
a. Olanzapine tablet - Give 0.5 milligram (mg- unit of measure) tablet by mouth two times a day for schizophrenia manifested by angry outbursts towards staff, dated 10/04/2023.
b. Monitor episodes of angry outburst towards staff and record number of episodes every shift for Olanzapine use, dated 10/04/2023.
A review of Resident 74's Care Plan for Antipsychotic Medication, indicated a goal that Resident 74 is prescribed an antipsychotic (medication that mainly treats psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality]-related conditions and symptoms) medication, Olanzapine, manifested by angry outbursts towards staff. The care plan indicated Resident 74 will have less than three episodes of the behavior in a week for 90 days, initiated on 10/04/2023. The care plan indicated an intervention to monitor behavior manifestation every shift and record that behavior.
During an interview with Licensed Vocational Nurse 1 (LVN 1) on 11/02/2023 at 4:21 p.m., LVN 1 stated that Resident 74 has angry outburst towards staff in which he has yelled at staff in the past. LVN 1 stated every time Resident 74 has this behavior, it is recorded on the residents Medication Administration Record (MAR- a record that documents all the medications provided to a resident by a healthcare professional) for each shift. LVN 1 stated the behavior should be more specific since an angry outburst may be a physical manifestation to one licensed nurse and a verbal manifestation to another. LVN 1 stated the behavior needs to be specific, so that the staff know if the medication is effective.
During an interview with Certified Nursing Assistant 1 (CNA 1) on 11/02/2023 at 4:53 p.m., he stated he provides care to Resident 74 on the 3:00 p.m. to 11:00 p.m. shift. CNA 1 stated Resident 74 will yell when he wakes Resident 74 in his wheelchair and attempts to put him back to bed. CNA 1 stated Resident 74 has yelled on other occasions for no reason.
During an interview with the Director of Nurses (DON) on 11/03/2023 at 8:48 a.m., DON stated that when Resident 74 was first admitted the resident was not calm and would become angry and physically strike out against nursing staff. The DON stated Resident 74's behavior needs to be a specific behavior to know if the medication is effective in treating that target behavior (specific behavior selected to change). The DON stated this was important because an antipsychotic can have negative side effects (undesirable effect of a medication or treatment) and should not be given unnecessarily.
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 proper sanitation and food handling practices by:
1. Failing to ensure a red sanitation bucket (contains sanitizing s...
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Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by:
1. Failing to ensure a red sanitation bucket (contains sanitizing solutions with a recommended concentration of a chemical sanitizer, usually quaternary [Quat, potent chemical disinfectant] ammonium [an ingredient in many household cleaning products] compounds or chlorine [a type of sanitizing solution]), located in the dish washing area of the kitchen, for the quaternary solution registered at the required 200 parts per million (ppm- unit of measure, 200 ppm indicates the sanitizing solution is effective) as per facility policy.
2. Failing to ensure kitchen staff completely submerged (to cover and overflow with water) frozen food items in a deep pot and failed to ensure the food in the deep pot was under running water with a temperature of 70 degrees Fahrenheit (° F- unit of measure) while thawing (frozen food becoming liquid or soft because of warming) the frozen food.
These deficient practices had the potential to place 78 of 91 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).
Findings:
1. During a concurrent observation and interview with Dietary Aide (DA) on 11/01/2023 at 2:43 p.m., observed a red bucket located in dish washing area of the kitchen. DA stated the red bucket located in the dish washing area of the kitchen was a sanitation bucket. DA was then observed checking the concentration level of the quaternary sanitizing solution inside the red bucket located in the dish washing area of the kitchen. Observed the results from the red sanitation bucket to reading zero (0) ppm. AD stated that all sanitization buckets should have a minimum test reading of 200 ppm per facility policy to ensure surfaces are disinfected and sanitized when cleaned.
During an interview with the Dietary Supervisor (DS) on 11/01/2023 at 2:55 p.m., the DS stated that the red bucket sanitizing solution should read at least 200 ppm and should be changed when the solution is cloudy and as needed (reading below 200 ppm).
The facility's policy and procedure titled Quaternary Ammonium Log Policy, reviewed 08/17/2023, indicated that the concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution. The food & nutrition worker will place the solution in the appropriate bucket labeled for its contents and will test the concentration of the sanitation solution. The concentration will be tested at least every shift or when the solution is cloudy. The solution will be replaced when the reading is below 200 ppm.
2. During a concurrent observation and interview with DA on 11/1/2023, at 2:49 p.m., observed frozen food items in a deep pot under running water in the kitchen. DA stated that the food items in the deep pot are frozen and are being thawed. DS stated that all food items inside the deep pot were not completely submerged under water. When asked if frozen food items should be submerged under water when thawing, DA stated frozen food items do not need to be submerged underwater, as long as there is water running over the frozen food item.
During an interview with the DS on 11/01/2023 at 4:49 p.m., when the DS was to describe the thawing process, the DS stated frozen food items should be placed in a container with running water over it. DS stated that all products must be under running water and that thawing time should be within two to three hours. The DS further stated that the temperature of the running water needed to be lower than 70°F. DS stated that kitchen staff should check to ensure that the running water used when thawing food is at the appropriate temperature of lower than 70° F.
During an interview with the Registered Dietician (RD) on 11/02/2023 at 10:45 a.m., RD stated that when thawing frozen food under running water, frozen food items are placed in a container under cold running water. Frozen food items do not have to be submerged in water, if cold water that is at least 70° F is running over frozen food items.
The facility's policy and procedure titled Thawing of Meats, reviewed 08/17/2023, indicated thawing meat can be done in four ways 3. Submerged under running, portable water at a temperature of 70°F or lower, with a pressure sufficient to flush away loose particles
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected multiple residents
Based on interview, and record review, the facility failed implement the facility's hospice (care designed to give supportive care to a resident in the final phase of a terminal illness [illness that ...
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Based on interview, and record review, the facility failed implement the facility's hospice (care designed to give supportive care to a resident in the final phase of a terminal illness [illness that cannot be cured] and focus on comfort and quality of life) policy and procedure for one of one sample residents (Resident 133) by failing to ensure Resident 133's hospice binder (the binder that contains the hospice services calendar, plan of care including interventions, nursing notes for a resident who is on hospice services) was in the facility to ensure communication between the hospice and the facility, and to ensure continuity of care for the hospice resident.
This deficient practice had the potential to delay coordination and delivery of hospice services.
Findings:
A review of Resident 133's Face Sheet (admission Record) indicated the facility admitted the resident on 10/12/2023, with diagnoses that included malignant neoplasm of the brain (brain cancer).
A review of Resident 133's Minimum Data Set (MDS - an assessment and care screening tool), dated 10/18/2023, indicated Resident 133 was moderately impaired in cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 133 required one-person moderate assistance (helper does less that half the effort) with personal hygiene and maximum assistance (helper does more than half the effort) with dressing.
A review of Resident 133's Physician's Orders indicated an order to admit the resident to hospice care, dated 10/12/2023.
A review of Resident 133's Care Plan for Limited Life Expectancy, initiated 10/12/2023, indicated a goal that Resident 133 will be kept safe and comfortable throughout the disease process daily for 90 days. The care plan indicated an intervention to provide hospice care as ordered.
During an interview with Licensed Vocational Nurse 1 (LVN 1) on 11/01/2023, LVN 1 searched for Resident 133's hospice binder but was unable to find the resident's hospice binder. LVN 1 stated a hospice resident should have a hospice binder that contains what care will be carried out for a resident under hospice services. LVN 1 stated this was important so that the hospice licensed nurses are able to communicate in written form to the facility's licensed nurses what interventions were conducted and any assessments that occurred during their visit. LVN 1 stated that she was unable to recall the last time the hospice nurse visited Resident 133 because there were no records at this time of past visits. LVN 1 stated the hospice binder is needed for continuity of care, such as any changes the facility licensed nurses need to follow-up with and to ensure that those services indicated in the resident's care plan are followed. LVN 1 stated she did not know how long the hospice binder for Resident 133 had been missing but will follow-up with the hospice service to find out what services were conducted for Resident 133.
During an interview with the Medical Records Director (MRD) on 11/03/2023 at 11:00 a.m., MRD stated that he had just called Resident 133's Hospice Service Provider to follow-up regarding Resident 133's missing hospice binder.
During an interview with Medical Records Assistant 2 (MRA 2) on 11/03/2023 at 11 a.m., The MRA 2 stated the MRD was told that the hospice binder would be delivered to the facility later that day on 11/3/2023.
During an interview with the Director of Nurses (DON) on 11/03/2023 at 11:55 a.m., DON stated there should have been a hospice binder available the day when hospice services were first provided to Resident 133. DON stated the facility's licensed nurses need to have access to Resident 133's hospice binder so they ensure the hospice services are being provided according to the resident's care plan.
During an interview with the Assistant Director of Nurses (ADON) on 11/03/2023 at 4:00 p.m., the ADON stated a resident's hospice binder should be at the nurses' station for licensed nurses to review any hospice nurse documentation including assessments and plan of care.
A review of the facility's policy and procedure titled, Hospice Services, reviewed 8/17/2023, indicated the hospice agency retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness. The policy and procedure indicated the hospice and facility should communicate with each other when any changes are indicated or made to the plan of care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its antibiotic stewardship(the effort to measure and impr...
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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 antibiotic stewardship(the effort to measure and improve how antibiotics [a medication used to treat or prevent infections] are prescribed and used by residents) program by failing to conduct infection surveillance (a tool to monitor the health of the residents) and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for four (Resident 9, Resident 74, Resident 130, and Resident 132) of five sampled residents.
This deficient practice had the potential for Resident 9, Resident 74, Resident 130 and Resident 132 to develop antibiotic resistance (when germs like bacteria change over time and no longer respond to medicines) from unnecessary or inappropriate antibiotic use for future infections.
Findings:
a. A review of Resident 9's Face Sheet (admission Record) indicated the facility admitted the resident on 12/16/2022 and re-admitted on [DATE] with diagnoses that included chronic osteomyelitis (a bone infection causing bone pain and recurring drainage) to right tibia (large bone at the front of the lower leg) and fibula (smaller and thinner leg bone than the tibia, positioned on the lateral side of the tibia).
A review of Resident 9' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/22/2023, indicated Resident 9 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 9 required one-person extensive assistance (resident involved in activity; staff provide weight-bearing support) with bed mobility, dressing and personal hygiene.
A review of Resident 9's Physician's Orders, dated 10/13/2023, indicated an order for Zyvox (an antibiotic that is used to treat bacterial infections) tablet 600 milligrams (mg - a unit of measure), give by mouth two times a day for Methicillin Resistant Staphylococcus Aureus (MRSA - a group of difficult-to-treat bacteria that are resistant to several antibiotics) of the right leg and knee wound for 42 days, dated 9/21/2023.
During a record review and concurrent interview with the Infection Preventionist (IP) on 11/02/2023 at 10:39 a.m., reviewed Resident 9's medical records for documented evidence that an Infection Surveillance Data Collection form (a systematic collection of data to track infection which is collected when a resident has certain signs and symptoms that could be a bacterial infection) was completed from 6/17/2023 to 11/2/2023, no documented evidence was found by the IP. The IP stated once a resident is prescribed an antibiotic, an infection surveillance form should be created. The IP stated licensed nursing staff use the McGeer criteria (a criteria of signs and symptoms that must be met to qualify for an infection as being a true infection and requiring the use of an antibiotic). The IP stated, if the resident does not meet the criteria for the illness to be a true infection, the resident's physician is notified, and the physician decides if they want to continue the antibiotics, or to discontinue it. The IP stated for Resident 9, licensed nursing staff should have completed an infection surveillance form. The IP stated it is important that each resident prescribed an antibiotic should have an infection surveillance form created so that a resident's physician can then be made aware if they do not meet the McGeer criteria for infection. The IP stated this was important to ensure that a resident is not prescribed an antibiotic unnecessarily because a resident could develop resistance to an antibiotic and would cause health complications for future infections.
During an interview with the Director of Nurses (DON) on 11/03/2023 at 8:48 a.m., DON stated that an infection surveillance form should be completed for any resident prescribed an antibiotic so that the facility staff can track infections in the facility. The DON stated that completing the infection surveillance form is also important so that the medication is justified in its use and to hopefully prevent building antibiotic resistance for future infections which could result in illness and possible hospitalization.
b. A review of Resident 74's Face Sheet indicated the facility admitted the resident on 7/15/2023, with diagnoses that included pneumonia (PNA, a bacterial lung infection).
A review of Resident 74's MDS, dated [DATE], indicated Resident 74 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 74 required moderate assistance (helper does less than half the effort) with eating, and transfer from bed to wheelchair.
A review of Resident 74's Physician's Orders indicated an order for Cefepime (a type of antibiotic used to treat bacterial infection) Intravenous (IV, a medical technique that administers fluids and medications directly into a person's vein) Solution - give one gram (gm - unit of measure) intravenously two times a day for PNA, dated 10/02/2023.
A review of Resident 74's Care Plan for IV Therapy, initiated 10/04/2023, indicated a goal that Resident 74's PNA will be resolved after completion of IV therapy.
During a record review and concurrent interview with the IP on 11/02/2023 at 10:39 a.m., reviewed Resident 74's medical records for documented evidence that an Infection Surveillance Data Collection form was completed from 7/15/2023 to 11/2/2023, no documented evidence was found by IP. The IP stated once a resident is prescribed an antibiotic, an infection surveillance form should be created. The IP stated licensed nursing staff use the McGeer criteria. The IP stated, if the resident does not meet the criteria for the illness to be a bacterial infection, the resident's physician is notified, and the physician decides if they want to continue antibiotics, or to discontinue it. The IP stated for Resident 74, licensed nursing staff should have completed an infection surveillance form. The IP stated it is important that each resident prescribed an antibiotic should have an infection surveillance form created so that a resident's physician can then be made aware if they do not meet the McGeer criteria for infection. The IP stated this was important to ensure that a resident is not prescribed an antibiotic unnecessarily because a resident could develop resistance to an antibiotic and would cause health complications for future infections.
During an interview with the DON on 11/03/2023 at 8:48 a.m., DON stated that an infection surveillance form should be completed for any resident prescribed an antibiotic so that the facility staff can track infections in the facility. The DON stated that completing the infection surveillance form is also important so that the medication is justified in its use and to hopefully prevent building antibiotic resistance for future infections which could result in illness and possible hospitalization.
c. A review of Resident 130's Face Sheet indicated the facility admitted the resident on 8/07/2023 and re-admitted [DATE], with diagnoses of infection to the internal right hip prosthesis (hardware placed inside the body during hip replacement surgery).
A review of Resident 130's MDS, dated [DATE], indicated Resident 130 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 130 required set-up help (helper sets up and resident completes the activity) with dressing, and personal hygiene and eats independently.
A review of Resident 130's Physician's Orders indicated an order for Ceftriaxone Sodium Injection Solution (a type of antibiotic used to treat bacterial infections), give two grams intravenously every 24 hours for osteomyelitis (bone infection) of right hip surgical site until 12/19/2023.
A review of Resident 130's Care Plan for IV Therapy, initiated 9/25/2023, indicated a goal that Resident 130's osteomyelitis of right hip surgical site will be resolved after completion of IV therapy.
During a record review and concurrent interview with the IP on 11/02/2023 at 10:39 a.m., reviewed Resident 130's medical records for documented evidence that an Infection Surveillance Data Collection form was completed from 9/25/2023 to 11/2/2023, no documented evidence was found by IP. The IP stated once a resident is prescribed an antibiotic, an infection surveillance form should be created. The IP stated licensed nursing staff use the McGeer criteria. The IP stated, if the resident does not meet the criteria for the illness to be a bacterial infection, the resident's physician is notified, and the physician decides if they want to continue antibiotics, or to discontinue it. The IP stated for Resident 130, licensed nursing staff should have completed an infection surveillance form. The IP stated it is important that each resident prescribed an antibiotic should have an infection surveillance form created so that a resident's physician can then be made aware if they do not meet the McGeer criteria for infection. The IP stated this was important to ensure that a resident is not prescribed an antibiotic unnecessarily because a resident could develop resistance to an antibiotic and would cause health complications for future infections.
During an interview with the DON on 11/03/2023 at 8:48 a.m., DON stated that an infection surveillance form should be completed for any resident prescribed an antibiotic so that the facility staff can track infections in the facility. The DON stated that completing the infection surveillance form is also important so that the medication is justified in its use and to hopefully prevent building antibiotic resistance for future infections which could result in illness and possible hospitalization.
d. A review of Resident 132's Face Sheet indicated the facility admitted the resident on 10/17/2023 and re-admitted on [DATE], with diagnoses that included left lower limb (lower leg) cellulitis (a common, potentially serious bacterial skin infection in which the affected skin is swollen and inflamed).
A review of Resident 132's MDS, dated [DATE], indicated Resident 132 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 132 required setup assistance with eating and personal hygiene.
A review of Resident 132's Physician's Orders indicated an order for Vancomycin (a type of antibiotic used to treat bacterial infections) IV Solution, give one (1) gram IV in the afternoon for left lower extremity cellulitis until 10/30/2023, dated 10/27/2023.
A review of Resident 132's IV Therapy Care Plan, initiated 10/17/2023, indicated Resident 132 needs IV therapy for an antibiotic medication. The care plan indicated a goal that cellulitis of the left leg will be resolved after completion of IV therapy.
During a record review and concurrent interview with the IP on 11/02/2023 at 10:39 a.m., reviewed Resident 132's medical records for documented evidence that an Infection Surveillance Data Collection form was completed from 10/24/2023 to 11/2/2023, no documented evidence was found by IP. The IP stated once a resident is prescribed an antibiotic, an infection surveillance form should be created. The IP stated licensed nursing staff use the McGeer criteria. The IP stated, if the resident does not meet the criteria for the illness to be a bacterial infection, the resident's physician is notified, and the physician decides if they want to continue antibiotics, or to discontinue it. The IP stated for Residents 132, licensed nursing staff should have completed an infection surveillance form. The IP stated it is important that each resident prescribed an antibiotic should have an infection surveillance form created so that a resident's physician can then be made aware if they do not meet the McGeer criteria for infection. The IP stated this was important to ensure that a resident is not prescribed an antibiotic unnecessarily because a resident could develop resistance to an antibiotic and would cause health complications for future infections.
During an interview with the DON on 11/03/2023 at 8:48 a.m., DON stated that an infection surveillance form should be completed for any resident prescribed an antibiotic so that the facility staff can track infections in the facility. The DON stated that completing the infection surveillance form is also important so that the medication is justified in its use and to hopefully prevent building antibiotic resistance for future infections which could result in illness and possible hospitalization.
A review of the facility's policy and procedure titled, Infection Control, Antimicrobial Stewardship, reviewed 8/17/2023, indicated the facility is implementing an antibiotic stewardship program to optimize clinical outcomes, while minimizing unintended consequences of antimicrobial use. The policy and procedure indicated the facility will collect and review types of antibiotic ordered including route of administration, whether the order was made by phone, if the order was the attending physician or on-call doctor, whether a culture (a test to find germs (such as bacteria or a fungus) that can cause an infection) was obtained before ordering the antibiotic, whether the antibiotic was changed during the course of treatment and a separate report for the number of residents on antibiotics that did not meet McGeer's criteria for active infection.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed ensure that four of 38 resident rooms (room [ROOM NUMBER]...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed ensure that four of 38 resident rooms (room [ROOM NUMBER], 3, 9 and 11) met the square footage requirement of 80 square feet (sq. ft.- unit of measure) per resident. Rooms 1, 3, 9 and 11 had two beds in each room.
This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the resident.
Findings:
On 10/31/2023, the Administrator (ADM) provided a copy of the Client Accommodation Analysis Form (a form that documents the square footage of resident rooms). A review of the Client Accommodation Analysis indicated that four of 38 rooms did not have at least 80 square feet per resident.
The Room Waiver Request Form and Client Accommodation Analysis Form indicated the following:
Room No.
Bed Capacity:
Room Sq. Footage:
Sq. Ft. per Resident
1
2
146
73.0
3
2
155
77.5
9
2
143
71.5
11
2
151
75.5
During a follow-up interview with the ADM, the ADM stated there should be at least 80 square feet per resident in multiple resident rooms. The minimum requirement for a 2-bed room should be at least 160 sq. ft.
A review of the Room Variance letter dated 11/01/2023, indicated, These rooms (Rooms 1,3,9 and 11) were slightly smaller than required. However, there is adequate space for our residents in these rooms. The rooms are in accordance with the special needs of residents and would not have an adverse effect on the residents' health and safety or impede the ability of any resident in the room to attain his/her highest practicable well-being.
During the recertification survey from 10/30/2023 to 11/03/2023, observed both residents and staff with enough space to move about freely inside Rooms 1,3,9 and 11. Observed that there was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing staff for the residents.
On 11/02/2023 at 4:53 p.m., during an interview, Certified Nursing Assistant 4 (CNA 4) stated he had no issues with the room sizes when it came to resident care for Rooms 1,3,9 and 11.
Aug 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
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure that two of two facility freezers (Freezer 1 and Freezer 2) were being maintained to good working conditions that provi...
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Based on observation, interview and record review, the facility failed to ensure that two of two facility freezers (Freezer 1 and Freezer 2) were being maintained to good working conditions that provide a safe environment for the residents.
This deficient practice had the potential to compromise the integrity of the food and placed 83 of 90 residents who received food from the kitchen at risk for foodborne illnesses (illness caused by the ingestion of contaminated food or beverages).
Findings:
During a concurrent observation and interview with Dietary Supervisor (DS) on 7/28/2023 at 3:57 p.m., in the kitchen, Freezer 1 internal temperature was at 18 degrees (°- unit of measure) Fahrenheit (F- unit of measure) and Freezer 2 temperature was at 14.9°F.
During a concurrent observation and interview with Dietary Staff 2 (DS 2) on 7/29/2023 at 1:28 p.m., Freezer 1 internal temperature was at 12°F and Freezer 2 internal temperature was 15.3°F.
During an interview with the Maintenance Supervisor (MS) on 7/29/2023 at 2:06 p.m., he stated that on 7/28/2023, there was an issue with keeping the required temperature for both freezers. MS stated that on 7/28/2023, he called the repair company to check both freezers. On 7/29/2023, the repairman informed him that the fan motor (part of the overall refrigeration system that pulls air through the coils to remove heat from the circulating air) for freezer 2 needs to be changed (will be delivered on 7/31/2023) and both freezers require additional freon (non-combustible gas that is used as refrigerant in air conditioning applications). MS stated that the staff would call him regarding any issues with any equipment and will see if he can fix it or if he needed to call the repair company.
During an interview with Dietary Staff 1 (DS 1) on 7/29/2023 at 2:39 p.m., she stated that on 7/28/2023 at around 6:00 p.m., Freezer 1 internal temperature was at 15°F. DS 1 stated that she reported the issue to DS and to MS.
During a concurrent interview and record review with DS on 7/29/2023 at 3:21 p.m., the facility ' s policy and procedure (P&P) titled Cold Storage Temperature with a revised date of 2018 was reviewed. The P&P indicated freezer temperature standards are 0°Fahrenheit or below. DS stated that the freezer temperature should be 0°F or below to ensure food remains in a frozen state. The DS stated the freezer temperature must maintain the required temperature to prevent compromising the integrity of the food stored in the freezer.
During a concurrent observation and interview with DS on 7/30/2023 at 1:02 p.m. in the kitchen, freezer 1 and freezer 2 were observed. DS stated that the temperature for freezer 1 was at - 4°F and freezer 2 temperature was at 7.6°F.
During a concurrent interview and record review with DS on 7/30/2023 at 1:15 p.m., the Cold Storage Temperature Log dated 7/29/2023 was reviewed. DS confirmed that the internal temperature for freezer 1 and freezer 2 on 7/29/2023 were as follows:
1. On 7/29/2023 at 11:30 a.m., freezer 1 temperature was noted at eight °Fand Freezer 2 temperature was noted at 13°F.
2. On 7/29/2023 at 12:30 p.m., freezer 1 temperature was noted at 10°F and Freezer 2 temperature was noted at 15°F.
3. On 7/29/2023 at 1:30 p.m., freezer 1 temperature was noted at 14°F and freezer 2 temperature was noted at 19°F.
4. On 7/29/2023 at 2:30 p.m., freezer 1 temperature was noted at 11°F and freezer 2 temperature was noted at 15°F.
5. On 7/29/2023 at 3:30 p.m. freezer 1 temperature was noted at 16°F and freezer 2 temperature was noted at 10°F.
6. On 7/29/2023 at 4:30 p.m. freezer 1 temperature was noted at 18°F and freezer 2 temperature was noted at five °F.
7. On 7/29/2023 at 5:30 p.m. freezer 1 temperature was noted at 0°F freezer 2 temperature was noted at 15°F.
8. On 7/29/2023 at 6:00 p.m. freezer 1 temperature was noted at 0°F freezer 2 temperature was noted at 18°F.
The DS stated that both freezers are not maintaining the internal temperature of zero° and below.
During a concurrent interview and record review with DS on 7/31/2023 at 3:55 p.m. the facility ' s undated P&P titled Refrigerator and Freezer was reviewed. DS stated that it is the kitchen staff ' s responsibility to ensure that the refrigerator and freezers are working efficiently. The kitchen staff must inform the maintenance staff if an issue is identified such as temperature or unusual noise.
During an interview with the Director of Nursing (DON) and DS on 8/3/2023 at 4:00 p.m., the DS stated that the use of freezer 2 was stopped on 7/30/2023. The DON stated that on 8/3/2023, a new freezer was delivered to replace Freezer 2.
A review of the facility ' s P&P titled Cold storage temperature logging with a revised date of 2018, indicated that food and nutrition services staff shall review and record temperatures of all refrigerators and freezers to ensure they are at the correct temperature for food storage and handling. It also indicated that food and nutrition services staff will check the inside temperature of refrigerators and freezers. They will record and initial the temperatures on the Cold Storage Temperature Log at the beginning of the morning and afternoon shifts. If the temperatures are not within standards, staff will notify the Director. In the Director ' s absence, the staff must notify both the Maintenance and the Administrator. It further indicated that freezer temperature standards are 0 degrees Fahrenheit or below.
A review of facility ' s P&P titled Preventative Maintenance Policy dated 7/2023, indicated it is the facility ' s policy to maintain a preventative maintenance program for all physical plant systems and equipment, including equipment in all departments. It also indicated that facility considers a preventative maintenance program an essential element in the elimination and prevention of unsafe environments . The P&P indicated that the Maintenance Supervisor will ensure:
A. A preventative maintenance program is adhered to, and that all physical plant systems and equipment be completed by appropriate qualified individuals.
B. Maintenance staff are aware of the building and physical plant processes and appropriately trained to complete preventative maintenance program schedules.
C. A preventative maintenance program is in place for all equipment, as well as all schedule frequencies for preventative maintenance. Schedules and frequencies for preventative maintenance are to be determined by Maintenance Supervisor, Administrator and in conjunction with the manufactures specification, best practices, local legislation, and any other industry recommendations.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to produce medical records within two (2) days of a written request by...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to produce medical records within two (2) days of a written request by the legal representative for one (1) of three (3) residents (Resident 1) as per facility's policy and procedure.
This deficient practice violated Resident 1's legal representative's right to access Resident 1's medical records in a timely manner.
Findings:
A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnosis of a urinary tract infection (UTI - type of infection that happens in the urinary system) and altered mental state (confused or not thinking clearly).
A review of Resident 1's Minimum Data Set (MDS- as assessment and care screening tool) dated 1/11/23, indicated the resident had the ability to make self-understood and had the ability to understand others.
During a concurrent interview and record review on 7/6/23 at 3:35 p.m., the Medical Records Director (MRD) reviewed the facility's Record Release Log for June of 2023. MRD stated that it is the responsibility of the MRD to provide requested resident medical records. The MRD stated that Resident 1's medical records were requested on 6/20/23 by the resident's legal representatives. MRD stated that Resident 1's medical records had still not yet been released.
During an interview on 7/6/23 at 6:10 p.m., the MRD stated that on 6/30/23 she notified Resident 1's legal representatives that Resident 1's medical records were ready to be released. MRD stated that it took 10 days for the request for Resident 1's medical records by Resident 1's legal representative to be provided. The MRD stated that per the facility policy, Resident 1's medical records should have been provided to Resident 1's legal representatives within two (2) days of the request.
A review of the facility's policy and procedure titled, Health Information Records Manual-Resident Access to Records, dated 12/14/20, indicated to provide access to copies of records within 48 hours.
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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's right to be free from verbal abuse for one of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's right to be free from verbal abuse for one of two sampled residents (Resident 1) when the facility's Certified Nursing Assistant 1 (CNA 1) told the resident to shut up while providing care for the resident.
This deficient practice resulted with Resident 1 feeling like she did something wrong and disrespected by CNA 1 while under the care of the facility.
Findings:
A review of Resident 1's admission Record, indicated the resident was originally admitted to the facility on [DATE] with a diagnosis Human Immunodeficiency Virus Disease (HIV - a virus that attacks the immune system).
A review of Resident 1's History and Physical, dated 4/29/2023, 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 screening tool), dated 04/25/2023, indicated the resident requires extensive assistance by a staff member for activities of daily living.
During an interview on 5/9/2023 at 10:30 a.m., Resident 1 stated that on 5/3/2023 sometime between 2:00 a.m. to 3:00 a.m., she needed assistance being cleaned after a bowel movement. Resident 1 stated that CNA 1 was assisting with cleaning the resident and when the resident hurried her with the cleaning process, CNA 1 told the resident to shut up because she was already helping her. Resident 1 stated the CNA's statement made her feel like she did something wrong. She stated that she felt it was demeaning and disrespectful, and that she felt hurt by the CNA's words.
During an interview on 5/9/2023 at 12:10 p.m., CNA 1 stated she was assigned to Resident 1 on the night of the incident around 2:00 a.m. on 5/3/2023. CNA 1 admitted to telling Resident 1 to shut up. CNA 1 stated that she wanted the resident to be quiet, so she told her to shut up. CNA 1 stated that she should not have said that to the resident because it's wrong. CNA 1 stated that she was frustrated and the words shut up just came out of her mouth. She stated that she should not have said that to the resident and should have just walked away and got somebody for assistance. When asked what verbal abuse is, CNA 1 stated that it is when you say something bad to a patient.
During a concurrent interview and record review on 5/9/2023 at 12:50 p.m., the Director of Nursing (DON) indicated, what CNA 1 said to the resident is considered verbal abuse per the facility's policy. The DON stated that the CNA should have removed her from the situation and not used those words to the resident.
A review of the facility's policy titled, Abuse Reporting and Prevention , dated 1/2023, indicated it is the policy of the facility to ensure that the resident rights are protected. The policy indicated that Verbal abuse is the use of language that willfully used derogatory or disparaging terms regardless of their age, ability to comprehend, or disability.
May 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
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 protect resident ' s right to be free from physical 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 protect resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by:
1. Resident 1 for one of two sampled residents (Resident 2). On 4/28/2023, Resident 1 threw a water pitcher (container) which hit Resident 2 ' s head.
2. Resident 2 for one of two sampled residents (Resident 1). On 4/28/2023, Resident 2 threw his cane which hit Resident 1 ' s head.
These deficient practices resulted in Resident 1 having to go to the General Acute Care Hospital (GACH) to receive sutures (a stitch or a row of stitches holding together the edges of a wound) for a laceration (a deep cut or tear in the skin) caused by Resident 2 hitting him with his cane; and Resident 2 sustaining a mid-forehead and left eyebrow skin tear (a wound that happens when the layers of skin separate) caused by Resident 1 hitting him with a water pitcher.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 4/17/2023 with diagnoses including syncope (fainting or passing out) and collapse, history of falling, and fracture (a broken bone) of nasal bones (bones located in the nose).
A review of Resident 1 ' s Long-Term Care (LTC) Skilled Initial History and Physical (H&P-the starting point of the resident ' s ' story ' as to why they sought medical attention or are now receiving medical attention), dated 4/18/2023, indicated that Resident 1 did 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 4/24/2023, indicated that Resident 1 had the ability to make himself understood and to understand others. The MDS indicated that Resident 1 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required limited one-person assistance from staff for bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, and eating.
A review of Resident 1 ' s Situation-Background-Assessment-Recommendation (SBAR) Communication Form (a tool used to facilitate prompt communication regarding a change in a resident ' s health condition), dated 4/28/2023, indicated that Resident 1 was involved in a resident-to-resident physical altercation on 4/28/2023. The SBAR indicated that on 4/28/2023 at approximately 12:00 p.m., the case manager witnessed Resident 1 throw his cane at Resident 2 after Resident 2 had thrown a pitcher at Resident 1 ' s head. The SBAR indicated that Resident 1 was then noted with a laceration to his left eyebrow as a result of being hit with Resident 2 ' s cane.
A review of Resident 1 ' s Physician ' s Orders, dated 4/28/2023, indicated to transfer Resident 1 to the GACH for a left eyebrow laceration needing sutures.
A review of Resident 1 ' s GACH Summary (a document given to a resident after a medical appointment intended to summarize the resident ' s health), dated 4/28/2023, indicated the Resident 1 was seen at the GACH for a head injury and left eyebrow laceration, which was repaired with sutures.
A review of Resident 1 ' s Skin and Body Assessment, dated 4/28/2023 at 8:00 p.m., indicated this was an assessment done upon the resident ' s return from the hospital. The resident was noted to have a left eyebrow laceration with sutures.
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 4/1/2023 with diagnoses including metabolic encephalopathy (a disorder that causes brain dysfunction) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning).
A review of Resident 2 ' s History and Physical Examination form, dated 4/3/2023, indicated the resident can make his needs known but cannot make medical decisions.
A review of Resident 2 ' s MDS, dated [DATE], indicated the resident had the ability to make himself understand and to understand others. The MDS also indicated that Resident 2 had severely impaired cognition and required extensive one-person assistance from staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene.
A review of Resident 2 ' s SBAR Communication Form, dated 4/28/2023, indicated that after Resident 1 threw his cane at Resident 2, Resident 2 sustained a mid-forehead and left eyebrow skin tear.
A review of Resident 2 ' s Skin and Body Assessment, dated 4/28/2023, indicated the resident sustained a skin tear to the mid-forehead and left eyebrow.
On 5/1/2023 at 3:05 p.m., during a concurrent observation and interview, Resident 1 was sitting on a chair at his bedside reading a book. Resident 1 had dark red laceration with sutures on the left eyebrow. When Resident 1 was asked if he was able to recall the incident with Resident 2 on 4/28/2023, Resident 1 stated no. Resident 1 then stated that he did not want to answer any further questions.
On 5/1/2023 at 3:34 p.m., during an interview, Case Manager 1 (CM 1) stated that on 4/28/2023 at around 12:00 p.m., he was passing by the nurses ' station when he heard yelling coming from Resident 1 and Resident 2 ' s room. CM 1 stated that he saw Resident 2 throw a water pitcher at Resident 1. CM 1 stated that, in response to being hit in the head with a water pitcher, Resident 1 threw his cane at Resident 2 ' s head. CM 1 stated he immediately grabbed Resident 1 to separate the two residents.
On 5/1/2023 at 4:44 p.m., during an interview, the Administrator (ADM) stated that he was the facility ' s abuse coordinator. ADM stated that the incident on 4/28/2023 between Resident 1 and Resident 2 could be considered abuse since both residents threw things (cane and water pitcher) at each other. When ADM was asked if the incident on 4/28/2023 between Resident 1 and Resident 2 where both residents were throwing objects at each other would be physical abuse even though no fists were involved, the ADM stated, Yes, they abused each other. It ' s resident-to-resident abuse. When asked if he considered both residents ' actions to be deliberate, ADM stated, Was it deliberate that they threw things at each other? Yes, it was. I would say that was deliberate.
A review of the facility ' s policy and procedure titled, Abuse Reporting and Prevention, last reviewed on 1/2023, indicated that a resident-to-resident altercation should be reviewed as a potential situation of abuse. The policy further stated that if the resident ' s actions were willful or deliberate then abuse has occurred. The policy indicated that Abuse means the willful infliction of injury. The policy indicated that physical abuse is a willful physical action that is meant to inflict physical harm, pain, or mental anguish.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 policy and procedures on bowel and bladder retraining...
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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 policy and procedures on bowel and bladder retraining program for one of three sample residents (Resident 1). Resident 1 was not placed on a retraining program, a care plan specific to the bowel and bladder retraining was not developed and the Bowel and Bladder Assessment form was not completed quarterly.
This deficient practice had the potential for Resident 1 not to attain Resident 1's highest functional level.
Findings
A review of Resident 1's admission Record indicated the facility admitted the resident on 7/21/2022 with diagnoses including left hip fracture (broken bone), right leg above the knee amputation (removal of a limb), and urinary tract infection (UTI, an infection in any part of the urinary system).
A review of Resident 1's Bowel and Bladder assessment dated [DATE], indicated a score of 11. For a score between 10 and 14, provide scheduled toileting plan.
A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 1/12/2023, indicated Resident 1 had moderate cognitive impairment (obvious difficulty with problem-solving, remembering names and details, and may withdraw socially as new situations and places are challenging). Resident 1 required extensive assistance with bed mobility, dressing, and personal hygiene. Resident 1 was totally dependent on staff for toilet use.
On 1/24/2023 at 2:58 p.m., during an interview with the MDS Coordinator (MDSC) and a review of Resident 1's Bowel & Bladder assessment dated [DATE], the MDSC stated that Resident 1 was incontinent (loss of control) of bowel and bladder. The MDSC stated there was no documentation Resident 1 was placed on a bowel and bladder retraining program or a scheduled toilet program. The MDSC stated there was no documentation of a care plan specific to Resident 1's bowel and bladder retraining program. The MDSC stated a Bowel and Bladder Assessment should be done quarterly and as needed if there were any significant changes in the resident's condition; however, Resident 1's Bowel and Bladder Assessment re-evaluation was missed.
A review of the policy and procedure titled, Bowel and Bladder Retraining Program, revised on 1/2017 indicated the purpose of the bowel and bladder retraining program is to attempt to assist the incontinent resident regain as much of his or her ability to control bowel and bladder functions. Upon admission, a bowel and bladder assessment will be completed for each resident. A re-evaluation will be completed at least quarterly and with a significant change in condition to determine if the resident is a candidate for retraining program. The documentation is to include date and time the bowel and bladder retraining program was initiated; the date, time, amount and character of each bowel movement or void, if possible; any problems voiced by the staff or by the resident; if the resident refused and the reason why the resident refused, if able to obtain; and the signature and title of the person documenting the date. After the initial assessment, residents who qualify for a bowel and/or bladder retraining program will be monitored through a daily.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 is unable to carry out activities of daily living (ADLs - transfer, walking, grooming, personal hygiene,...
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Based on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs - transfer, walking, grooming, personal hygiene, bathing, and eating) receives services to maintain good grooming for one of eight sampled residents (Resident 2) whosse fingernails were long and soiled.
This deficient practice resulted in Resident 2's poor groomer.
Findings:
A review of Resident 2's admission Record indicated the facility admitted the resident on 12/23/2022 with diagnoses including complete traumatic amputation (the loss or removal of a body part) at level between left hip and knee, and type 2 Diabetes Mellitus (DM - a chronic condition that affects the way the body processes blood sugar).
A review of Resident 2's History and Physical exam, dated 12/24/2022, indicated the resident was able to make decisions.
A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 12/29/2022, indicated the resident was able to communicate needs and required extensive assistance by two staff with bed mobility, toilet use, and personal hygiene.
A review of Resident 2's Care Plan dated 1/4/2023 indicated, the resident required extensive assistance with hygiene. The goal was for the resident to be well-groomed daily. One of interventions was to provide assistance with personal hygiene.
On 1/12/2023 at 11:27 a.m., during an interview with Resident 2 and a concurrent observation of Resident 2's long and soiled fingernails, Resident 2 stated requesting the nursing staff to cut them but it was not done yet.
On 1/12/2023 at 11:30 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated he noticed the resident's fingernails needed to be cleaned and cut yesterday, but forgot to cut his fingernails.
On 1/12/2023 at 11:52 a.m., during an interview with the Director of Nursing (DON) and concurrent observation of Resident 2's fingernails, the DON verified that staff needed to trim and clean Resident 1's fingernails immediately.
A review of the facility's policy and procedures dated June/2022, titled, Activities of Daily Living, Quality of Care, Routine Resident Monitoring, and Scope of Services indicated, It is the policy of the facility that each resident receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and the psychosocial well-being consistent with the resident's comprehensive assessment and plan of care Staff will ensure that ADL are monitored, assisted with, and provided for those residents who are unable to perform ADL If resident is unable to carry out ADL, they are to be provided services to maintain good nutrition, grooming and personal and oral hygiene.
Dec 2022
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 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 resident ' s call light was within reach for o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident ' s call light was within reach for one of three sampled residents (Resident 2). Resident 2 ' s call light was on the floor and not within reach on 12/15/2022.
This deficient practice placed the resident at risk of falls and needs not met as the Resident 2 was unable to get staff assistance.
Findings:
A review of Resident 2 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 11/9/2022 with diagnoses left hip fracture (broken bone) and osteopenia (bones becoming brittle and fragile).
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 11/15/2022, indicated that the resident usually understood others and was usually understood by others. Resident 2 required limited assistance with bed mobility, transfers, and personal hygiene. Resident 2 required extensive assistance for dressing, and totally dependent on staff for toilet use.
A review of Resident 2 ' s Fall Risk assessment dated [DATE], indicated the resident was a high risk for falls.
A review of Resident 2 ' s Care Plan, dated 11/9/2022 indicated, the resident was risk for fall/injury due to impaired mobility. The interventions included placing the call light within reach and answer it promptly.
During a concurrent observation and interview, on 12/15/2022 at 1:26 p.m., in Resident 2 ' s room, Certified Nursing Assistant 1 (CNA 1) verified that Resident 2 ' s call light was on the floor. CNA 1 stated that probably the call light slid from the bed and dropped on the floor. CNA 1 placed the call light within reach for Resident 2, but she did not use the clip attached to the call light cord to prevent from falling off the bed. When CNA 1 was asked about the call light clip, she stated did not see the clip on the cord. CNA 1 stated the clip on the cord maintained the call light in place. Resident 2 ' s call lights should be placed within reach all the times to call for staff assistance.
During an interview, on 12/15/2022 at 4:40 p.m., the Director of Nursing (DON) stated that the resident ' s call lights should be within reach of residents at all the times, and staff should check for the call light placements. The DON stated if the residents were unable to get their call lights when they need help, they might try to move without assistance and increase fall risks.
A review of the facility ' s policy and procedures revised 1/2017, titled Call Lights indicated, It is the policy of the facility to respond to the resident ' s requests and needs . When the resident is in bed or in the wheelchair or chair in the room, staff should make sure that the call light is within each reach of the resident Call lights should be answered promptly.
Oct 2022
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide dignity and respect for Resident 62 when Certified Nursing Assistant (CNA 1) was observed standing over the resident w...
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Based on observation, interview, and record review the facility failed to provide dignity and respect for Resident 62 when Certified Nursing Assistant (CNA 1) was observed standing over the resident while assisting with her meal, for one of two sampled residents.
This deficient practice had the potential to affect Resident 62's sense of self-worth and self-esteem.
Findings:
A review of the Face Sheet indicated the facility admitted the resident on 8/11/2022 with diagnoses including unspecified dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes and impaired reasoning).
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/15/2022, indicated Resident 62 had the ability to make self-understood and understand others. The MDS indicated Resident 62 required extensive assistance with bed mobility and supervision when eating.
A review of care plan titled Nutritional Status, initiated on 8/22/2022, indicated Resident 62 was at risk for alteration in nutritional status. The care plan's interventions were for staff to encourage food intake/diet as ordered, to monitor tolerance to diet texture/consistency, and to notify the doctor if difficulties were noted.
A review of care plan titled Activities of Daily Living (ADL) Functional/Rehabilitation Potential, initiated on 8/22/2022 indicated Resident 62 required assistance area in ADLS and eating (limited). The care plan's interventions were for staff to encourage the resident to participate and foster independence with ADLs.
During a concurrent observation and interview, on 10/13/2022 at 7:43 a.m., Resident 62 was observed sitting up in bed with bed in lowest position. CNA 1 observed standing over on right side of Resident 62 without a chair assisting Resident 62 with feeding. CNA 1 stated she forgot to get a chair and wanted to assist Resident 62 with feeding. CNA 1 stated that she should be sitting at eye level when feeding resident. CNA 1 stated if she was not eye level, it could affect the residents' dignity and self-worth.
During an interview, on 10/13/2022 at 9:19 a.m., the Director of Nursing (DON) stated that staff should be feeding residents at eye level and if they did not it could be an issue with dignity.
During an interview, on 10/13/2022 at 2:43 p.m., the Administrator (Adm) stated it was a dignity issue for the CNA to be standing while feeding Resident 62.
A review of facility's policy and procedures titled Resident's Right to Dignity and Privacy, revised on 8/23/2022, indicated it is the policy of the facility that each resident shall be cared for in a manner that promotes dignity, respect and individuality and provides for resident privacy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 59's Face Sheet indicated the facility admitted the resident on 2/01/2021 with diagnoses including muscl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 59's Face Sheet indicated the facility admitted the resident on 2/01/2021 with diagnoses including muscle weakness, type 2 diabetes mellitus (a condition that affects the way the body regulates and uses blood sugar), and transient ischemic attack (TIA - a temporary blockage of blood flow to the brain).
A review of Resident 59's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/5/2022, indicated the resident had visual impairment. The MDS indicated Resident 59 was usually able to make self-understood and to understand others. The MDS indicated Resident 59 required one-person extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and required total dependence with bathing.
A review of Resident 59's Activity of Daily Living (ADL) Care Plan (care plan - contains relevant information about a resident's diagnosis, goals of treatment, specific nursing orders and evaluation plan), dated 8/5/2022, indicated Resident 59 was at risk for further decline in function secondary to right upper extremity (limb) contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten or become stiff). The Care Plan indicated the use of adaptive devices and supportive equipment to ensure safety during ADL as one of the interventions (any action a nurse performs to help residents reach desired outcomes).
A review of Resident 59's Vision Care Plan, dated 8/5/2022, indicated Resident 59 had impaired visual function and at risk for further decline in vision and falls or injuries related to diabetes and aging process. The Care Plan indicated to keep all personal things and items in same location and within easy reach and ensure adequate lighting in room and hallways.
During an observation, on 10/13/2022 at 8:30 a.m., Resident 59 was in bed and asked staff to turn off his light. The overhead light switch was observed in a string behind the resident and was not within Resident 59's reach.
During a concurrent observation and interview, on 10/13/2022 at 9:54 a.m., in Resident 59's room, CNA 1 observed Resident 59 calling and asking for the light to be turned off. The light switch was observed in a string behind Resident 59 and not within reach. CNA 1 stated Resident 59 was not able to reach the light switch because the string was too short. CNA 1 was observed to try to tie the string with the call light cord, but the string came loose. CNA 1 stated that not being able to reach the light switch could cause Resident 59 to get frustrated.
During a concurrent observation and interview, on 10/13/2022 at 10:02 a.m., in Resident 59's room, Licensed Vocational Nurse 1 (LVN 1) observed light switch in a string behind Resident 59's bed and not within Resident 59's reach. LVN 1 stated Resident 59 was not able to reach the light switch because it was too short. LVN stated they could have made the string longer so that Resident 59 could easily reach and be able to use it himself. LVN 1 stated the short light switch did not accommodate Resident 59's needs and could cause harm to Resident 59 such as emotional distress.
A review of the facility's policies and procedures (P&P), reviewed 8/23/2022, titled, Resident Rights, indicated, Policy Goal: Promote the exercise of rights for each resident, including any who face barriers (such as communication problems, vision or hearing problems and cognition limits) in the exercise of these rights. To reside and receive services with reasonable accommodation of resident needs and preferences unless to do so would endanger the health or safety of the resident or other residents.
Based on observation, interview, and record review the facility failed to ensure a call light was within reach for three (Residents 24, 141, and 59) of four sampled residents who had limited range of motion and visual impairment by failing to provide a light switch that was within the residents' reach.
These deficient practices had the potential to result in injuries from falls and accidents when the residents were unable to summon for help from staff.
Findings:
a. A review of Resident 24's Face Sheet indicated the facility admitted the resident on 7/02/2022 with diagnoses including asthma (long term disease of swelling of the airways of the lungs), muscle weakness, and difficulty walking.
A review of Resident 24's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/11/2022, indicated Resident 24 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 24 required two-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility and transfer and walking in the room.
A review of Resident 24's Activities of Daily Living (ADL) Care Plan, initiated 7/02/2022, indicated Resident 24 needed assistance with ADLs. The ADL Care Plan indicated an intervention to keep the call light within easy reach.
During an interview, on 10/12/2022 at 8:15 a.m., Resident 24 stated staff placed her in her wheelchair facing the window. Resident 24 stated she was not given a call light and was not able to see the hallway to see if any staff were passing if she needed to call them. Resident 24 stated she had lunch in the wheelchair facing the window and felt frustrated she could not see staff to call them for assistance.
b. A review of Resident 141's Face Sheet indicated the facility admitted the resident on 9/29/2022 with diagnoses including difficulty in walking and infection to left knee prosthesis (left knee replacement).
A review of Resident 141's MDS, dated [DATE], indicated Resident 141 was cognitively intact with skills required in daily decision making. The MDS indicated Resident 41 required one-person extensive assistance with walking and transfer.
A review of Resident 140's Face Sheet indicated the facility admitted the resident on 9/24/2022 with diagnoses including difficulty walking and generalized muscle weakness.
A review of Resident 140's MDS, dated [DATE], indicated Resident 140 was cognitively intact with skills required in daily decision making. The MDS indicated Resident 140 required two-person extensive assistance with bed mobility and dressing.
During an observation and interview, on 10/12/2022 at 11:19 am., Resident 141 was observed sitting in her wheelchair facing the window with no call light within reach. Resident 141 stated her roommate (Resident 140) pressed her call light to call staff since her call light was out of reach. Resident 140 stated she pressed the call light to call staff for Resident 141. Resident 141 stated she would feel anxious and frustrated if Resident 141 was not in the room to call staff for her.
During an observation and interview with Certified Nursing Assistant 2 (CNA 2), on 10/13/2022 at 11:46 am., she stated if a resident sat in their wheelchair facing away from the hallway, the call light should be placed near the foot of the bed so a resident could call staff. CNA 2 demonstrated moving the call light to the foot of the bed so that it would be within reach of a resident sitting in a wheelchair near the bed.
During an interview with the Director of Nurses (DON), on 10/13/2022 at 4 p.m., she stated residents' call lights need to be within reach. The DON stated a resident's quality of life could be negatively affected if a resident's call light was out of reach of the resident.
A review of the facility's policy and procedure titled, Call Lights, reviewed 08/23/2022, indicated when the resident is in bed or in the wheelchair or chair in the room, staff should make sure that the call light is within easy reach of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
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's discharge Minimum Data Sets (MDS - a standardiz...
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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's discharge Minimum Data Sets (MDS - a standardized assessment and care screening tool) was transmitted within 14 days after the assessment reference date (ARD - the specific end point of look-back periods in the MDS assessment process) for two (Residents 1 and 3) out of four sampled residents investigated for resident assessment.
This deficient practice had the potential to result in delayed services for the residents.
Findings:
a. A review of Resident 1's Face Sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis including metabolic encephalopathy (brain disease). The Face Sheet indicated the resident was discharged on 8/22/2022.
A review of the Centers for Medicare and Medicaid Services (CMS - a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program) Submission Report indicated the Assessment Completed Date for section Z0500B (assessment completion date) for Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) was more than 14 days after A2300 (assessment reference date).
During a concurrent interview and record review, on 10/14/2022 at 10:14 a.m., the Minimum Data Set Nurse (MDSN) stated Resident 1 was admitted to the facility on [DATE] and discharged on 8/22/2022. MDSN stated the resident's discharge assessment had not been done yet. MDSN stated the resident's discharge MDS should have been submitted by 9/18/2022.
During an interview, on 10/14/2022 at 1:12 p.m., the Director of Nursing (DON) stated it was important to submit the MDS on time for the accuracy of the residents' assessments.
A review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual indicated the MDS must be transmitted (submitted and accepted into the QIES ASAP system) electronically no later than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days).
b. During a concurrent interview and record review, on 10/13/2022 at 3:52 p.m., the MDSN stated the facility was behind with the submission of MDS due to another staff on medical leave.
A review of Resident 3's Face Sheet indicated the facility admitted the resident on 5/29/2022 with diagnosis including metabolic encephalopathy (a problem in the brain caused by chemical imbalance in the blood from infections, dehydration, and alcohol toxicity). The record indicated Resident 3 was discharged on 8/22/2022.
During a concurrent interview and record review, on 10/14/2022 at 10:14 a.m., the MDSN stated Resident 3 was admitted to the facility on [DATE] and discharged on 8/22/2022. MDSN stated the resident's discharge assessment had not been done yet. MDSN stated the resident's discharge MDS should have been submitted by 9/18/2022.
During an interview, on 10/14/2022 at 1:12 p.m., the Director of Nursing (DON) stated it was important to submit the MDS on time for the accuracy of the residents' assessments.
A review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual indicated the MDS must be transmitted (submitted and accepted into the QIES ASAP system) electronically no later than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days).
A review of the facility's policy and procedure titled, Resident Assessment Instrument (RAI), dated 4/2017, indicated the facility will transmit MDS assessments in accordance with the transmission dates outlined.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to develop a baseline care plan for Resident 293, within 48 hours from admission for hearing impairment, for one of one sampled r...
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Based on observation, interview and record review, the facility failed to develop a baseline care plan for Resident 293, within 48 hours from admission for hearing impairment, for one of one sampled resident.
This deficient practice had the potential for delayed provision of necessary care and services.
Findings:
A review of Resident 293's Face Sheet indicated the resident was admitted to the facility, on 10/04/2022, with diagnoses including diarrhea, vomiting, weakness, and failure to thrive. A review of Resident 293's initial assessment indicated Resident 293 was alert, oriented, and needed help with activities of daily living (ADLs).
During an observation, on 10/11/22 09:14 a.m., Resident 293 was in the yellow zone (an area where Residents are under investigation for COVID-19 - contagious lung disease). Resident 293 was in bed awake. Resident 293 stated she did not feel well today for stomach cramps from the salmonella infection (diarrheal infections caused by the bacteria salmonella). Resident 293 refused interview because she was hard of hearing.
During an interview, on 10/12/22 09:09 a.m., Resident 293 stated she was using hearing aids. Resident 293 was still hard of hearing from 6 feet. away and requested pen and paper to communicate. Resident expressed frustration due to her inability to hear.
A review of Resident 293's initial assessment, dated 10/4/22, indicated that there was no mention of the hearing aids and hearing impairment was not noted.
A review of Resident 292's care plan (contains relevant information about a resident's diagnosis, goals of treatment, specific nursing orders and evaluation plan) indicated that there was no documented evidence of a care plan for hearing impairment.
During an interview, on 10/13/22 at 09:14 a.m., Licensed Vocational Nurse 1 (LVN 1) stated that there was no care plan for impaired hearing. LVN1 stated she would create a care plan for impaired hearing. LVN 1 stated that it could create frustration to the residents if they could not hear.
A review of undated policy titled Care Planning- Interdisciplinary Team, indicated the Interdisciplinary Team is responsible in the development of individualized resident-centered comprehensive care plan for each residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 58's Face Sheet indicated the facility admitted the resident, on 8/12/2022 with diagnoses including Wern...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 58's Face Sheet indicated the facility admitted the resident, on 8/12/2022 with diagnoses including Wernicke's encephalopathy (a type of brain injury caused by a lack of the nutrient thiamine), and anemia (a condition that develops when blood produces lower than normal amount of healthy red blood cells).
A review of Resident 58's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/19/2022, indicated the resident had severe cognitive impairment and required one-person extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene.
A review of Resident 58's Physician Orders for Life-Sustaining Treatment (POLST), dated 8/15/2022, indicated DNR and comfort-focused treatment - primary goal of maximizing comfort.
During a concurrent interview and record review, on 10/12/2022 at 8:33 a.m., there was no documented evidence of a DNR care plan. The Assistant Director of Nursing (ADON) stated a care plan was initiated to include a resident's goals, needs, problems, and contain the interventions that the facility would follow when providing services to a resident. The ADON stated without a DNR care plan, Resident 58 was placed at risk for discomfort and potential for not honoring the interventions specified for DNR such as monitoring for pain or discomfort and monitoring for nutritional and hydration status.
During an interview, on 10/14/2022 at 10:30 a.m., Licensed Vocational Nurse 1 (LVN 1) stated a DNR care plan should be initiated so that staff were aware of what to do in the event of an emergency. LVN 1 stated it was important to keep DNR residents comfortable according to their plan of care.
A review of the facility's policy and procedure, dated 1/2017, titled, Care Planning - Interdisciplinary Team, indicated it is the policy of the facility that the Interdisciplinary Team is responsible for the development of an individualized resident centered comprehensive care plan for each resident.
b. A review of Resident 22's Face Sheet indicated the resident was originally admitted to the facility, on 9/21/2021 and readmitted on [DATE], with a diagnosis of autistic disorder.
A review of Resident 22's MDS, dated [DATE], indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive one-person assistance for bed mobility, dressing, toilet use, and personal hygiene.
During a concurrent observation and interview, on 10/11/2022 at 9:59 a.m., Resident 22 was awake in bed. Resident 22 stated she was just readmitted to the facility yesterday.
During a concurrent interview and record review, on 10/12/2022 at 8:24 a.m., the Administrator (ADM) verified on Form CMS-672 (Resident Census and Conditions of Residents) there were two residents in the facility with an intellectual and/or developmental disability. ADM stated Resident 22 had autism.
During a concurrent interview and record review, on 10/12/2022 at 9:44 a.m., the Minimum Data Set Nurse (MDSN) verified Resident 22 had a documented diagnosis of autistic disorder. When asked if the resident had a care plan addressing her diagnosis, MDSN stated she could not find in the resident's medical record that there was a specific care plan addressing her autistic disorder.
During an interview, on 10/14/2022 at 1:03 p.m., the Director of Nursing (DON) stated Resident 22 should have had a care plan addressing her diagnosis of autism disorder because the staff that cared for her would know how to deal with any behavior she might have associated with her autism.
A review of the facility's policy and procedure titled, Care Planning - Interdisciplinary Team, last updated on 8/23/2022, indicated it is the policy of the facility that the Interdisciplinary Team is responsible for the development of an individualized resident-centered comprehensive care plan for each resident. The care plan is based on the resident's needs and the resident's comprehensive assessment.
Based on interview and record review, the facility failed to develop a care plan (CP-a care plan helps nurses and other care team members organize aspects of patient care according to a timeline) for:
1. Addressing the residents` change of condition pertaining to an open wound on the right foot between the 4th and 5th toe on 08/10/2022 for one of one sampled resident (Resident 46).
This deficient practice has the potential for delay in wound healing.
2. Resident 22 with a diagnosis of autistic disorder (a developmental disability caused by differences in the brain. People with ASD often have problems with social communication and interaction, and restricted or repetitive behaviors or interests) for one out of one resident sampled for intellectual disability.
This deficient practice had the potential to result in failure to deliver the necessary care and services required for a resident diagnosed with autistic disorder.
3. Resident 58 who has a do-not-resuscitate status (DNR) with comfort-focused treatment.
This deficient practice had the potential to result in care or services that were inconsistent with Resident 58's individual goals and desired outcomes.
Findings:
a. A review of Resident 46`s Face Sheet indicated the resident was admitted to the facility, on 08/17/2022, with diagnoses including hyperlipidemia (an abnormally high concentration of fats in the blood), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty).
A review of Resident 46's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/01/2022, indicated Resident 48'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 Resident 46 required limited assistance for transfer, dressing, toilet use, and for personal hygiene.
During an observation, on 10/11/2022 at 9:48 a.m., Resident 46 was lying in bed watching television. Resident 46 stated he was admitted to the facility with some diabetic ulcer on both his plantar (lower) foot.
A review of Resident 46's Care Plan, dated 9/12/22, indicated Resident 46 was a high risk of skin breakdown and had an onset of diabetic ulcer (skin wound) between the 4th and 5th toe of the right foot. The Care Plan outlined multiple interventions including but not limited to keeping the resident clean and dry, out of bed as tolerated, and dietary consultation.
During a concurrent interview with the Minimum Data Set Nurse (MDSN) the nurses should have developed a care plan that was appropriate to the residents needs and for the skin alteration the resident had sustained. The MDSN stated without the care plan, there would be no specific approach or intervention on how to resolve the resident skin problem or condition. The MDSN stated if the change of condition occurred on 8/10/22 there should have been a care plan developed immediately which in this case the care plan was only initiated on 9/12/22.
A review of the facility`s undated policy, titled Care Planning-Interdisciplinary Team, indicate that it is the policy of the facility that the Interdisciplinary Team (nurses collaborate with patients, significant others, families, other nurses and other healthcare providers to solve patient care problems) is responsible for the development of an individualized resident centered comprehensive care plan for each resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow professional standards by not raising the head ...
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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 professional standards by not raising the head of the bed (HOB) for one (Resident 16) resident out of four residents observed during the medication administration observation. Resident 16 had a gastrostomy tube (G-Tube, a plastic tube inserted into the stomach so that a resident can receive medications directly because they can't swallow) that required the head of the bed to be at least thirty degrees.
This deficient practice had the potential for Resident 16 to acquire aspiration pneumonia (a lung infection that occurs when food or liquid is breathed into the airways or lungs).
Findings:
A review of Resident 16's Face Sheet indicated the facility admitted the resident on 6/20/2022 and re-admitted on [DATE] with diagnoses including dementia (a chronic or disorder of the mental processes marked by memory disorders, personality changes, and impaired reasoning) and presence of a G-Tube.
A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/11/2022, indicated Resident 24 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 16 required one-person total dependence (full staff performance every time) for eating (which includes nourishment by other means such as tube feeding).
A review of Resident 16's physician's orders, dated 12/20/2022, indicated aspiration precaution: elevate head of bed at least thirty to forty degrees at all times and monitor every shift.
A review of Resident 16's G-Tube Feeding Care Plan, initiated 6/29/2021, indicated Resident 16 required enteral nutrition feeding (G-Tube feeding). The Care Plan indicated Resident 16 would have no signs or symptoms of aspiration daily for ninety days. The Care Plan indicated to keep and maintain the resident's head of bed elevated at all times during feeding.
During a medication administration observation, on 10/13/202 at 10:01 am., Licensed Vocational Nurse 1 (LVN 1) was administering medications to Resident 16. LVN 1 administered one medication with the head of the bed less than 30 degrees. When asked if the HOB was thirty degrees, LVN 1 stated it was not and raised the head of bed to at least thirty degrees. LVN 1 stated the head of Resident 16's head of bed needed to be raised to prevent stomach contents from moving from the stomach and esophagus (the digestive tract that connects the throat to the stomach) into the lungs.
A review of the policy titled, Medication Administration, reviewed 8/23/2022, indicated medications are administered in accordance with written orders of the attending physician.
A review of the policy titled, Gastrostomy Tube Feeding via Continuous Pump, reviewed 8/23/2022, indicated to always keep the HOB greater than thirty degrees or as directed by the physician's order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide quality care to ensure a communication device was provided to Resident 293, for one of one sampled resident. This def...
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Based on observation, interview, and record review, the facility failed to provide quality care to ensure a communication device was provided to Resident 293, for one of one sampled resident. This deficient practice prevented the resident from communicating with the staff and had a potential to delay receiving appropriate care/treatment as needed.
Findings:
A review of Resident 293's Face Sheet indicated the facility admitted the resident, on 10/04/2022, with diagnoses that included diarrhea, vomiting, weakness, and failure to thrive. A review of Resident 293's initial assessment indicated that Resident 293 was alert, oriented, and needed help with activities of daily living (ADLs).
During an observation, on 10/11/2022 at 09:14 a.m., Resident 293 was in the yellow zone (an area where Residents were under investigation for COVID-19 - contagious lung disease). Resident 293 was awake in bed. Resident 293 refused interview because she was hard of hearing.
During an interview on 10/12/2022 at 09:09 a.m., Resident 293 stated she was using hearing aids. Resident 293 stated she was still hard of hearing from 6 feet away and requested pen and paper to communicate. Resident expressed frustration due to her inability to hear.
During an observation on 10/13/2022 at 08:22 a.m., Resident 293 was with Director of Staff Development (DSD) in the room helping with the food tray. Resident 293 stated she had her hearing aids on but asked for pen and paper. DSD stated that she could communicate but staff had to come closer and speak slowly. DSD asked Resident 293 if she needed pen and paper and Resident 293 said yes. DSD went to get Resident 293 a board and marker.
During an interview, on 10/23/2022 8:42 a.m., DSD stated that it could be frustrating for Resident 293 to not be able to hear the other person. DSD stated that the board and pen should be within the resident's reach and placed somewhere everyone could see.
A review of Resident 293's initial assessment, dated 10/04/2022, indicated that there was no mention of the hearing aids and hearing impairment was not noted in the record.
During an interview, on 10/13/2022 at 09:14 a.m., Licensed Vocational Nurse 1 (LVN 1) stated that it could create frustration to the residents if they cannot hear. LVN1 stated that there should be a communication board provided for Resident 293 to communicate to staff.
A review of the undated facility's policy titled Residents with Communication Barrier indicated that it is the policy of this facility to meet the needs of residents with communication barrier. Communication supports psychosocial well-being by enabling residents to participate in their care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of the Face Sheet indicated Resident 62 was admitted to the facility on [DATE] with diagnoses including unspecified ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of the Face Sheet indicated Resident 62 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), and psychosis not due to substance or known physiological condition (mental disorder characterized by a disconnection from reality).
A review of the MDS, dated [DATE], indicated Resident 62 had the ability to make self-understood and understand others. The MDS indicated Resident 62 required extensive assistance with bed mobility, and supervision when eating.
A review of the physician order report, dated 8/16/2022, indicated Resident 62 was on Boost VHC (high calorie nutritional supplement) liquid 120 milliliters (ml) oral three times a day.
A review of care plan titled Nutrition, initiated on 8/12/2022, indicated Resident 62 had a therapeutic diet. Interventions included to administer and serve diet as ordered, assist resident at mealtime as needed and to offer meal substitutional when meals were refused.
During an observation, on 1/13/2022 at 7:43 a.m., Resident 62 was sitting up in bed with Certified Nurse Assistant (CNA 1) standing over resident while assisting her with her meal. Resident 62 tray had a Boost Glucose (nutritional supplement for diabetes - condition causing low blood sugar) opened with a straw. CNA 1 stated that the Boost Glucose was already on the resident's tray when she came in.
During a concurrent observation and interview, on 10/13/2022 at 7:56 a.m., the Licensed Vocational Nurse (LVN 1) stated Resident 62 usually took Boost VHC. LVN 1 observed Boost glucose on Resident 62's tray. LVN 1 stated Resident 62 was not diabetic and should not be taking the Boost Glucose for it was not ordered. LVN 1 further stated that Resident 62 received Boost VHC to manage her weight loss and if she did not get the correct boost it may lead to Resident 62 losing weight.
During an interview, on 10/13/2022 at 9:19 a.m., the Director of Nursing (DON) stated Resident 62 was not a diabetic and had an order for high calorie boost. The DON stated if Resident 62 were to get Boost Glucose she would not be getting the ordered calories to maintain her weight.
During an interview, on 10/13/2022 at 2:43 p.m., the Administrator (Adm) stated if Resident 62 was getting the wrong boost, it could lead to Resident 62 not receiving the appropriately prescribed calorie intake.
A review of the facility's policy and procedure titled, Quality of Care, Routine Resident Monitoring and Scope of Services revised on 8/23/2022 indicated it is the policy of the facility that each resident receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care. Policy further stated facility will provide hygiene, bathing, dressing, grooming and oral care, mobility-transfer and ambulation including walking, toileting, dinning-eating, including meals and snack.
Based on interview and record review, the facility failed to provide resident centered care as evidenced by failure to:
1. Ensure physician`s order for treatment of left lower extremity wound were provided on multiple days in the month of 8/2022, for one of two sampled residents (Resident 46).
This deficient practice has the potential to negatively affect the resident's physical well-being.
2. Provide ordered nutritional supplement for one out of two sampled residents (Resident 62).
This deficient practice had the potential to negatively affect the resident's weight by lowering her calorie intake.
Findings:
a. A review of Resident 46`s Face Sheet indicated the resident was admitted to the facility, on 08/17/2022, with diagnoses including hyperlipidemia (an abnormally high concentration of fats in the blood), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty).
A review of Resident 46's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 8/01/2022, indicated Resident 48'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 Resident 46 required limited assistance for transfer, dressing, toilet use, and for personal hygiene.
A review of Resident 46`s Resident Care Plan: Pressure Ulcers (an injury that breaks down the skin and underlying tissue), indicated a problem of risk for skin breakdown related to diagnoses of diabetes with a goal to minimize any skin breakdown/pressure ulcer daily for 90 days. The Care Plan indicated interventions for staff to provide skin treatment as ordered.
A review of the Resident 46's physician`s order, dated 7/31/22, indicated an order for the left lower extremity discoloration to cleanse with normal saline, pat dry, apply vitamin A&D (skin protectant) twice a day for 30 days.
During a concurrent interview and record review, on 10/13/22 at 08:46 a.m., the Minimum Data Set Nurse (MDSN) stated on 8/03/2022, 08/07/2022, 08/17/2022, 08/20/2022 and 8/24/2022, there was no documentation that the treatments were provided on these dates. The MDSN stated that if there were no documentation it meant there was no treatment provided and could result to worsening of the skin impairment and infection.
A review of the facility`s policy and procedures, dated 1/2017, titled Quality of Care, Routine Resident Monitoring and Scope of Services, indicated that it is the policy of the facility that each resident receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being consistent with the resident`s comprehensive assessment and plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
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 Resident 293 an accessible means of communica...
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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 Resident 293 an accessible means of communicating for one (Resident 293) of one sampled resident investigated for vision and hearing care area.
This deficient practice resulted to Resident 293's inability to understand the healthcare staff which lead to frustration.
Findings:
A review of the Face Sheet indicated the facility admitted Resident 293 on 10/4/2022 with diagnoses that included unspecified dementia (decline in mental ability severe enough to interfere with daily functioning/life) and unspecified bilateral hearing loss.
A review of Resident 293's Initial Nursing History and assessment dated [DATE] indicated the resident was alert, oriented and needed assistance with activities of daily living (ADLs). The assessment also indicated Resident 293 was hard of hearing on both ears and used a hearing aid.
A review of Resident 293's Progress Notes dated 10/5/2022 indicated the resident was very hard of hearing. The Progress Notes also indicated Resident 293 has bilateral hearing loss and receives communication by writing and the resident repeats verbally.
On 10/11/2022 at 9:14 a.m., during an interview, Resident 293 refused to be interviewed because she was hard of hearing.
On 10/12/2022 at 9:09 a.m., during an interview with Resident 293, Resident 293 stated she was using hearing aids. Resident 293 was still hard of hearing from 6 feet (ft - unit of measure) away and requested pen and paper to communicate. Resident expressed frustration due to her inability to hear.
On 10/13/2022 at 8:22 a.m., during an observation, observed the Director of Staff Development (DSD) in Resident 293's room helping with the resident's tray. Resident 293 stated she has her hearing aids on but asked for pen and paper to communicate. The DSD stated that Resident 293 can communicate but the speaker has to come closer and speak slowly. Resident 293 insisted that she writes down so she can read and understand as she cannot make out the words with the masks on. The DSD asked Resident 293 if she needed pen and paper and resident 293 said yes. The DSD went to get Resident 293 a board and marker.
On 10/23/2022 at 8:42 a.m., during an interview, the DSD stated that it can be frustrating for not being able to hear the other person. The DSD stated that the board and pen should be within the resident's reach and placed somewhere everyone could see. The DSD stated she will educate the staff about caring for impaired hearing.
On 10/13/2022 at 9:14 a.m., Licensed Vocational Nurse 1 (LVN 1) stated that it can create frustration to the residents if they can't hear. LVN1 stated that there should be a communication board provided.
A review of the facility policy and procedures titled Residents with Communication Barrier, undated, indicated that it is the policy of the facility to meet the needs of residents with communication barriers. Communication supports psychosocial well-being by enabling residents to participate in their 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
Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LAL mattress - a mattress designed to prevent and treat pressure wounds), for a resident wi...
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Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LAL mattress - a mattress designed to prevent and treat pressure wounds), for a resident with a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), was set to the correct setting according to his weight, for one (Resident 197) out of one resident investigated for pressure ulcers.
This deficient practice had the potential to increase the resident's risk of developing new pressure ulcers or delay the healing process of already existing pressure ulcers.
Findings:
A review of Resident 197's Face Sheet indicated the facility admitted the resident on 10/5/2022 with diagnoses that included metabolic encephalopathy (a neurological disorder caused by a chemical imbalance in the blood), generalized muscle weakness, and history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) 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 197's Physician Order Report from 10/1/2022 to 10/31/2022 indicated the following orders:
1. Monitor sacrococcyx (area where the tailbone is) deep tissue injury (DTI - purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear); cleanse with normal saline (NS - a prescription medicine that can reduce some types of bacteria), pat dry, paint with betadine (used in a medical setting to help prevent infection and promote healing in skin wounds, pressure sores, or surgical incisions), cover with foam dressing daily x 30 days
2. Sacrococcyx extended to right and left buttock DTI: cleanse with NS, pat dry, apply skin barrier cream, cover with foam dressing daily x 30 days
3. LAL mattress for skin and wound management every shift
On 10/11/2022 at 10:34 a.m., during an observation, Resident 197 was awake in bed. Observed the resident's LAL mattress was observed to be on and was set to 350 pounds (lbs - unit of measure; was firm).
On 10/11/2022 at 10:54 a.m., during a concurrent observation and interview, Licensed Vocational Nurse 2 (LVN 2) stated that Resident 197 had a DTI on the sacrococcyx and redness around the sacrococcygeal area. LVN 2 verified that the LAL mattress was set to 350 lbs. LVN 2 stated the resident weighed 165 lbs. LVN 2 stated that the LAL mattress should have been set to 165 lbs. instead of 350 lbs.
On 10/14/2022 at 1:12 p.m., during an interview, the Director of Nursing (DON) stated the facility had three types of LAL mattresses. The DON stated for the ones that are not indicated in pounds, it should be set to the comfort level of the resident. The DON stated the LAL mattress that Resident 197 had was indicated in pounds, and since it was indicated in pounds, then it should have been set according to the resident's weight, which was 165 lbs. The DON added that the resident also had a wound, so it was especially important for his LAL mattress to be set correctly in order to help with his wound treatment.
A review of the facility's policy and procedure titled, Low Air Loss Mattress, last updated on 8/23/2022, indicated it is the policy of the facility to provide for the proper placement and management of a low air loss mattress when utilized by a resident.
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 observation, interview, and record review, the facility failed to:
1. Ensure one of two sampled residents (Resident 24) received restorative nursing assistant (RNA - one who provides physical...
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Based on observation, interview, and record review, the facility failed to:
1. Ensure one of two sampled residents (Resident 24) received restorative nursing assistant (RNA - one who provides physical exercises to maintain a resident's range of motion without decline) exercises during the week of 10/03/2022 as ordered by the physician.
2. Ensure there was a doctor's order and resident training for Resident 24's use of a trapeze (assistive device that hangs above the patient's bed that looks like a circus trapeze is used to help with movement and positioning of a patient).
This deficient practice had the potential to decrease Resident 24's range of motion and mobility which could affect her overall function. In addition, this deficient practice had the potential for self-injury when the resident was not properly trained training on using equipment.
Findings:
A review of Resident 24's Face Sheet indicated the facility admitted the resident on 7/02/2022 with diagnoses that included muscle weakness, difficulty walking, and an unstageable left upper posterior thigh (full thickness tissue loss in which depth of the ulcer is completely obscured by slough [dead tissue] in the wound bed of the back of the thigh).
A review of Resident 24's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/11/2022, indicated Resident 24 is moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 24 required two-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility and transfer, and walking in the room or corridor did not occur during the seven-day assessment period.
A review of Resident 24's Physician's Order, dated 9/29/2022, indicated RNA to do strengthening exercises to both upper and lower extremities using two pound (lb - unit of measure) dumbbells and ankle weights, five times a week.
A review of Resident 24's RNA Flowsheet for the month of October 2022, indicated during the week of 10/03/2022, there were five entries indicating the RNA documented RNA treatments five times that week. There was one of entries that was circled for 10/05/2022 (meaning no RNA treatments were provided that date), and an entry on the next page for 10/05/2022 which indicated Resident 24 was unable to do RNA treatments because Resident 24 went to dialysis treatment (purification of the blood by a machine for those without functioning kidneys) and charge nurse was aware. There was no documentation the RNA treatment was attempted at a different time or different day.
During an observation and interview with Resident 24 on 10/13/2022 at 3 p.m., she stated she was not getting her exercises enough times, only getting them three times a week. Observed a trapeze was observed above Resident 24's bed. Resident 24 stated she was not given any instruction from staff on how to use it or on safety concerns using a trapeze.
During an interview with the Director of Nurses (DON) and the Director of Rehabilitation (DOR) on 10/13/2022 at 4:12 pm., the DOR stated he did not know about the trapeze but he would get an order from the doctor and train Resident 24 on how to use safely so that she will not cause self-injury. The DON and DOR stated there should be a doctor's order for the use of the trapeze. The DON and DOR stated Resident 24 should receive RNA treatments five times a week as ordered by Resident 24's physician. The DOR stated staff should return at a different time or day to attempt to perform the RNA exercises when Resident 24 is in the facility.
During an interview with the Administrator (ADM) on 10/13/2022 at 5:30 pm., he stated the RNA should have returned a different time or day when Resident 24 was in the facility and able to perform the RNA exercises.
A review of the facility's policy and procedure titled, Restorative Nursing Assistant Referrals, revised 09/2022, indicated if a resident is screened and it is determined that the resident could benefit from therapy, the appropriate department will obtain a physician's order for treatment therapy. The policy indicated the RNA and the therapist providing the training will both sign the appropriate form to document the training.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was at high risk for falls had ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was at high risk for falls had floor mats (designed to reduce injuries from falls off of hospital beds) as ordered by the physician for one (Resident 67) out of two sampled residents investigated for accidents and hazards.
This deficient practice had the potential to increase the resident's risk for injury in the event of a fall.
Findings:
A review of Resident 67's Face Sheet indicated the facility admitted the resident on 10/1/2022 and readmitted on [DATE] with diagnoses that included unspecified fracture (broken bone) of upper end of left humerus (upper arm bone) with subsequent encounter for fracture with routine healing; multiple fractures of ribs, left side; with subsequent encounter for fracture with routine healing; and history of falling.
A review of Resident 67's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 9/5/2022, indicated the resident had severely impaired cognitive skills (thought process) for daily decision-making and required extensive assistance for bed mobility, transfers, walking in the room and in the corridor, dressing, eating, toilet use, and personal hygiene.
A review of Resident 67's Fall Risk Evaluation, dated 9/7/2022, indicated the resident was at high risk for falls.
A review of Resident 67's Physician Order Report from 10/1/2022 to 10/31/2022 indicated an order for low bed with mats on the floor.
On 10/11/2022 at 10:06 a.m., during an observation, Resident 67 was asleep in bed. The resident's bed was in the lowest position. Observed no mats on the floor.
On 10/12/2022 at 8:40 a.m., during an observation, Resident 67 was sitting up in bed awake. The resident's bed was in the lowest position. Observed no mats on the floor.
On 10/12/2022 at 9:57 a.m., during a concurrent observation and interview, the Minimum Data Set Nurse (MDSN) verified that the resident did not have floor mats at his bedside or in the room.
On 10/14/2022 at 9:17 a.m., during a concurrent interview and record review, the MDSN stated that Resident 67 had fallen in the facility on 9/7/2022. The resident was found lying on the floor at the foot of his bed. MDSN stated, in response, the physician placed an order for low bed with floor mats.
On 10/14/2022 at 2:15 p.m., during an interview, the Director of Nursing (DON) stated that one of the interventions for a fall risk resident was to provide for a floor mat to provide caution in case of an actual fall.
A review of the facility's policy and procedure titled, Fall Risk/Prevention, last updated on 8/23/2022, indicated it is the policy of the facility to identify residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure there was medical justification for the continuous use of an indwelling urinary catheter (a hollow flexible tube inser...
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Based on observation, interview, and record review, the facility failed to ensure there was medical justification for the continuous use of an indwelling urinary catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine) for one of one sampled resident (Resident 32) investigated under the care area of urinary catheter use.
This deficient practice had the potential to result in urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder or urethra]).
Findings:
A review of the Face Sheet indicated the facility admitted Resident 32 on 7/16/2022 with diagnoses including, urinary tract infection, acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar).
A review of the physician order dated 7/16/2022 indicated Resident 32 had Foley (name of an indwelling urinary catheter) catheter due to left hip wound.
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/21/2022, indicated Resident 32 had the ability to make self-understood and understand others. The MDS indicated Resident 32 requires extensive assistance with bed mobility, transfer, walking in room, walk in corridor, dressing, toilet use and personal hygiene. The MDS indicated Resident 2 had an indwelling catheter and one unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar [mass of dead tissue]) pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) that was present on admission.
A review of care plan titled Catheter Use, initiated on 7/16/2022, indicated Resident 32 is at risk for UTI and urinary trauma/injury due to the use of indwelling catheter: Foley catheter secondary to wound management. Interventions included to monitor for signs and symptoms of UTI and report to doctor.
During a concurrent observation and interview on 10/11/2022 at 10:16 a.m., observed Resident 32 with an indwelling catheter. Resident 32 stated she is not sure why she has a catheter; she was able to urinate before being admitted to the hospital on her own.
During an interview on 10/12/2022 at 3:09 a.m., with Registered Nurse (RN 1), RN 1 stated that Resident 32 was admitted with the Foley catheter for her wound that she acquired in her home. RN 1 stated that Resident 32 is ambulatory and is continent as far as she is aware. RN 1 stated that she would get a hold of the doctor to discontinue the catheter. RN 1 stated that Resident 32 no longer needs the catheter and extensive use of a catheter can lead to a risk for infection.
During an interview on 10/13/2022 at 9:33 a.m., with the Director of Nursing (DON), the DON stated that she did not think Resident 32 requires a Foley catheter as resident was able to ambulate. The DON stated Resident 32 can lose bladder control and can be at risk for infection.
During an interview on 10/13/2022 at 9:59 a.m., Resident 32 stated it has been a pain having a Foley catheter because she was able to go to the restroom on her own but cannot empty bag herself; she must walk with the heavy catheter bag in hand. Resident 32 stated she was never given a valid reason for having the Foley catheter; she was told it was because of the wound but the wound is nowhere near her catheter and she is not bedbound.
During an interview on 10/13/2022 at 2:43 p.m., with the Administrator (Adm), the Adm stated Resident 32 should have been assessed to see if she required a Foley catheter. The Adm stated Resident 32 was at risk for infection due to the Foley catheter use.
A review of the facility's policy and procedure titled Indwelling Catheter Use-Indications, revised on 8/23/2022 indicated an assessment must be documented to support the use of an indwelling catheter. Appropriate indication for the continued use of an indwelling catheter beyond the assessment period may include:
a. Document post-void residual (PVR- the amount of urine left in the bladder after urinating) volumes in a range over 200 milliliters (ml - unit of measure)
b. Inability to manage the retention/incontinence (loss of urine control causing to pass urine unexpectedly) with intermittent catheterization and,
c. Persistent overflow incontinence, symptomatic infections, and/or renal (kidney) dysfunction.
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 ensure the percentage of intake and administration of nutritional supplements were documented in the Medication Administration Record (MAR-...
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Based on interview and record review, the facility failed to ensure the percentage of intake and administration of nutritional supplements were documented in the Medication Administration Record (MAR- where medications and nutritional supplements given to a resident are documented) for one of two sampled residents (Resident 40) investigated under the care area of nutrition.
These deficient practices placed the resident at risk for delay in nutritional intervention if caloric intake from nutritional supplement is unknown which could result to weight loss for Resident 40.
Findings:
A review of Resident 40`s Face Sheet indicated the facility admitted the resident on 7/22/2022 with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure) and gastro-esophageal reflux disease ( digestive disease in which stomach acid or bile irritates the food pipe lining).
A review of Resident 40's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 7/29/2022, indicated that Resident 40's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making is severely impaired. The MDS also indicated that Resident 40 required extensive assistance for eating, transfer, dressing, toilet use, and for personal hygiene.
A review of the Resident 40`s physician`s order, indicated an order of the following:
1. Ensure Clear (nutritional supplement) liquid, 237 milliliter (ml - unit of measure) to give during medication pass and record percentage intake on the MAR, twice a day at 9 a.m. and 5 p.m., order dated 7/22/2022.
2. Boost VHC (nutritional supplement) liquid, 237 ml, to give three times a day and record percentage of intake on MAR, order dated 7/31/2022.
On 10/13/2022 at 2:57 p.m., during a record review and interview with Minimum Data Set Nurse (MDSN), the MAR indicated the following:
1. Ensure Clear - no documentation in the MAR if supplements were given on:
a. 8/3/2022 at 5 p.m.
b. 8/13/2022 at 5 p.m.
c. 8/15/2022 at 9 a.m.
d. 8/20/2022 at 5 p.m.
e. 8/23/2022 at 9 a.m.
f. 9/5/2022 at 5 p.m.
g. 9/28/2022 at 5 p.m.
2. Boost VHC- no documentation in MAR of percentage intake from 8/1/2022 to 8/25/2022 for the 9 a.m., 1 p.m., and 5 p.m. administration schedule.
The MDSN stated that the administration of the supplement should be documented to determine the resident`s intake percentage as the information is relevant in the management of the resident`s weight.
A review of the facility`s policy and procedure dated 2018, titled Nourishment Policy, indicated that it is the nursing department`s responsibility to see that each resident receives the nourishments as ordered.
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:
1. Label a breathing treatment medication, levalbuterol (generic name for a medication to help with breathing), with an open...
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Based on observation, interview, and record review, the facility failed to:
1. Label a breathing treatment medication, levalbuterol (generic name for a medication to help with breathing), with an open date (date written on a medication when it was first opened for use) for Resident 57 when required to ensure that they are discarded in accordance with the timeline specified by the manufacturer in one of two observed medication carts (Medication Cart 3).
The deficient practice of failing to label medications with an open date when required increased the risk of Resident 57 receiving a medication which may have become ineffective resulting in a negative impact to their health and well-being.
2. Ensure that Licensed Vocational Nurse 3 (LVN 3) signed the controlled drug record (a log signed by the licensed nurse with date and time a controlled medication [substances that have accepted medical use, have potential for abuse, and may also lead to physical and or psychological dependence] is given to a resident) after administering pregabalin (a controlled medication used to treat nerve pain) for Resident 29 in one of two observed medication carts (Medication Cart 3).
The deficient practice of failing to sign the controlled drug record had the potential to result in confusion in the care provided to Resident 29 in addition to drug loss and drug diversion (transfer of a medication from a legal to illegal use).
Findings:
a. A review of Resident 57's Face Sheet indicated the facility admitted the resident on 4/13/2022 with diagnoses that included pneumonia (lung infection).
A review of Resident 57's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/10/2022, indicated Resident 57 is moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making.
A review of Resident 57's Physician's Order, dated 4/13/2022, indicated an order for levalbuterol 0.63 milligrams (mg, a unit of measure) in 3 milliliters (ml, a unit of measure for a liquid), as needed, every six hours for cough/wheezing, administer one unit dose by hand-held nebulizer (HHN, which changes liquid to a mist so it can be inhaled in the lungs).
A review of Resident 57's Care Plan for Oxygen Use, initiated 4/13/2022, indicated Resident 57 was unable to maintain oxygen saturation (measurement of the amount of oxygen in the bloodstream) and receives oxygen at 2 liters (l, a unit of measure)/minute (min, a unit of time) to keep oxygen saturation greater than 92% (normal reference range 92% to 100%). The Care Plan indicated one of the interventions was an as needed order for levalbuterol by hand-held nebulizer.
During a medication observation on 10/12/2022 at 2:44 p.m. with LVN 3, observed an open package of levalbuterol 0.63 mg/3 ml with no date indicated on the package. LVN 3 stated there should be an open date since the medication is to be discarded after being open for a certain period of time.
A review of the levalbuterol 0.63 mg/3 ml package indicated once the medication pouch is open, the vials should be used within two weeks.
b. A review of Resident 29's Face Sheet indicated the facility admitted the resident on 8/26/2022 with diagnoses that included neuralgia (nerve pain) and neuritis (nerve inflammation).
A review of Resident 29's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/11/2022, indicated Resident 29 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 29 required one-person supervision with transfer and one-person set-up help only with walking.
A review of Resident 29's Physician's Orders, dated 8/26/2022, indicated an order for pregabalin 150 mg three times a day for neuropathic (nerve problem that causes pina, numbness, tingling, swelling in different parts of the body) pain.
During a medication cart observation and concurrent record review with LVN 3 on 10/12/2022 at 2:44 p.m., observed the bubble pack (clear package containing a medication in which the medication is pressed out of the package to remove) of pregabalin in Medication Cart 3. There were six pills left in the bubble pack. Reviewed Resident 29's pregabalin controlled drug record for the bubble pack which indicated there should be seven pills left for the pregabalin. LVN 3 stated she administered pregabalin that day earlier at 1 p.m. and signed the medication administration record (MAR) but did not sign the pregabalin controlled drug record. LVN 3 stated she should have signed the controlled drug record also but was in a hurry and did not get a chance to sign.
A review of Resident 29's October 2022 MAR indicated LVN 3 had signed that the pregabalin medication had been administered earlier on 10/12/2022 at 1 p.m.
A review of the facility's policy and procedure titled, Controlled Medications, reviewed 8/23/2022, indicated when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR.
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 ensure documentation of services rendered for two out of two sampled residents (Residents 13 and 40) investigated addressing accuracy of me...
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Based on interview and record review, the facility failed to ensure documentation of services rendered for two out of two sampled residents (Residents 13 and 40) investigated addressing accuracy of medical records by:
1. Failing to ensure that blood glucose (blood sugar) monitoring, lispro insulin (fast-acting medication that lowers the level of glucose in the blood) administration, Basaglar insulin (long-acting medication that lowers the level of glucose in the blood) administration, and metformin (medication in tablet form that lowers the level of glucose in the blood) administration were documented in the electronic Medication Administration Record (eMAR- where medications given to a resident are documented) on multiple dates and times for Resident 13.
2. Failing to ensure the administrations of metoprolol tartrate were documented and the resident's systolic blood pressure readings (SBP- measures the force the heart exerts on the walls of the arteries each time it beats) were documented in the MAR for Resident 40.
These deficient practices resulted to incomplete information that may lead to confusion in the care and services rendered and had the potential for poor management of Resident 13's type 2 diabetes mellitus (type 2 DM - an impairment in the way the body regulates and uses sugar [glucose] as a fuel), and Resident 40's hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure).
Findings:
a. A review of the Face Sheet indicated that the facility admitted Resident 13 on 6/18/2021 and readmitted the resident on 6/2/2022 with diagnoses that included type 2 DM.
A review of Resident 13's physician's orders indicated:
1. A start date of 7/17/2021 for Admelog SoloStar Insulin (brand name for lispro insulin) 12 units (unit of measure) subcutaneously (a method of administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) for DM. Special instructions: Rotate (a method to ensure repeated injections of insulin are not administered in the same area) injection sites. Check blood sugar before insulin administration. Inject within 15 minutes before meals (6:30 a.m., 11:30 a.m., 4:30 p.m.). Notify/call Medical Doctor/Nurse Practitioner (MD/NP) if blood sugar is greater than (>) 250 or less than (<) 60.
2. A start date of 6/18/2021 for Basaglar KwikPen Insulin 20 units subcutaneously at bedtime, 9 p.m. for DM. Special instructions: Rotate injection sites.
3. A start date of 6/18/2021 for Metformin 1000 milligrams (mg-unit of measure) oral (by mouth) for DM, to take with meals twice a day at 7:15 a.m. and 5:15 p.m.
A review of Resident 13's eMAR indicated that there were missing documentations for blood glucose and lispro insulin administration on:
1. 9/30/2022 for 7 a.m. to 3 p.m. shift
2. 9/2/2022 for 3 p.m. to 11 p.m. shift
3. 9/11/2022 for 3 p.m. to 11 p.m. shift
4. 9/24/2022 for 3 p.m. to 11 p.m. shift
On 10/12/2022 at 11:23 a.m., during an interview with Medical Record Director (MRD), MRD stated missing documentations meant that the nurse forgot to document or forgot to administer the medication.
On 10/13/2022 at 9:10 a.m., during an interview, Resident 13 stated that she always gets her insulin and her blood sugars were always checked prior to insulin administration.
On 10/13/2022 at 10:13 a.m., during an interview with Licensed Vocational Nurse 2 (LVN 2) and a concurrent record review of Resident 13's eMAR, LVN 2 stated there were missing documentations as follows:
1. For lispro insulin for 3 p.m. to 11 p.m. shifts on 9/2/2022, 9/11/2022, and 9/24/2022; and for 7 a.m. to 3 p.m. shift on 9/30/2022
2. For Basaglar insulin on 9/11/2022 for 3 p.m. to 11 p.m. shift
3. For Metformin for 7 a.m. to 3 p.m. shifts on 9/3/2022, 9/4/2022, 9/10/2022, 9/17/2022, 9/24/2022, and 9/30/2022
A review of the policy and procedures titled, Preparation and General Guidelines, dated 10/2017, indicated the individual who administers the medication dose records the administration the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medication.
b. A review of Resident 40`s Face Sheet indicated the facility admitted the resident on 7/22/2022 with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure)
A review of Resident 40's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 7/29/2022, indicated that Resident 40's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making is severely impaired. The MDS also indicated that Resident 40 required extensive assistance for eating, transfer, dressing, toilet use, and for personal hygiene.
A review of the Resident 40`s physician`s order indicated to administer
Metoprolol tartrate (can treat high blood pressure) 25 milligram (mg - unit of measure) orally (by mouth), hold (do not administer) for systolic blood pressure (SBP- measures the force the heart exerts on the walls of the arteries each time it beats) less than 110 millimeters of mercury (mmHg-unit of measure) or heart rate (HR) less than 60, twice a day at 7:15 a.m. and 5:15 p.m.
On 10/13/22 at 2:57 p.m., during a record review and interview with Minimum Data Set Nurse (MDSN), the MAR indicated no documentation of metoprolol tartrate administration and systolic blood pressure reading in the MAR on:
a. 8/3/2022 at 5:15 p.m.
b. 8/13/2022 at 5:15 p.m.
c. 8/19/2022 a 7:15 a.m.
d. 8/23/2022 at 7:15 a.m.
e. 9/13/2022 to 9/15/2022 at 7:15 a.m.
f. 9/20/2022 at 7:15 a.m.
The MDSN stated that blood pressure management includes ensuring medication orders are administered based on the parameter as ordered by the physician.
A review of the facility`s policy and procedure dated 10/2017 titled Medication Administration-Guidelines, indicated that medications are administered and prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The policy and procedures also indicated the resident`s MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to revise a care plan addressing urinary indwelling catheter (a hollow flexible tube inserted in the bladder through the urethra...
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Based on observation, interview, and record review, the facility failed to revise a care plan addressing urinary indwelling catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine) for one of one sampled resident (Resident 32).
This deficient practice had the potential to result in Resident 32 acquiring a urinary tract infection (UTI - an infection in any part of the urinary system, the kidneys, bladder, or urethra).
Findings:
A review of the Resident 32's Face Sheet indicated the facility admitted the resident on 7/16/2022 with diagnoses including urinary tract infection, acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar).
A review of the physician order dated 7/16/2022, indicated Resident 32 had Foley catheter due to left hip wound.
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/21/2022, indicated Resident 32 had the ability to make self-understood and understand others. The MDS indicated Resident 32 required extensive assistance with bed mobility, transfer, walking in room, walk in corridor, dressing, toilet use and personal hygiene. The MDS indicated Resident 2 had an indwelling catheter with one unstageable pressure ulcer (bed sore) that was present on admission.
A review of care plan titled Catheter use, initiated on 7/16/2022, indicated Resident 32 was at risk for UTI and urinary trauma/injury due to the use of indwelling catheter: Foley catheter secondary to wound management. The care plan's interventions included for staff to monitor for signs and symptoms of UTI and report to doctor.
A review of facility care plan titled Resident Care Plan, dated 7/21/2022, indicated Resident 32 was bowel and bladder were continent (able to control urinary and bowel function) with Foley catheter.
During a concurrent observation and interview, on 10/11/2022 at 10:16 a.m., Resident 32 was observed to have an indwelling catheter with dignity bag. Resident 32 stated she was not sure why she had a catheter was able to urinate before being admitted to the hospital on her own. Resident 32 stated facility had not told her why she required a catheter or could not recall.
During a concurrent interview and record review, on 10/13/2022 at 8:31 a.m., the Medical Records (MR) stated care plans were to be started upon admission. MR stated the initial care plan needed to be provided and care plans needed to initiate within 72 hours. MR stated Assistant Director of Nursing (ADON) was responsible for checking the charts within 24 hours after admission. MR stated that Resident 32 required a care plan for Foley catheter because it would necessitate nursing staff interventions for Foley catheter and gave duration.
A review of the facility's policy and procedure titled Comprehensive Care Planning revised on 8/23/2022 indicated care plan must be reviewed and revised periodically, at least quarterly, and on an ongoing basis to reflect changes in the resident.
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:
1. Ensure a plastic gait belt (a device put on a pat...
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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 a plastic gait belt (a device put on a patient who has mobility issues, by a caregiver prior to that caregiver moving the patient) was used instead of a cloth gait belt for five (Residents 46, 6, 56, 88, and 195) out of seven residents sampled for infection control.
These deficient practices had the potential to result in increasing the risk of spreading infection to residents and staff.
2. Ensure that a bottle of salad dressing, ranch dressing, ketchup and mayonnaise were refrigerated and not left at the resident`s bedside table for an unknown number of days for one of one sampled resident (Resident 51).
This deficient practice had the potential to result in ingestion of contaminated and spoiled condiments which could lead to food borne illnesses (illness caused by the ingestion of expired and contaminated food or food poisoning).
2. Ensure that vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) were obtained and monitored two times per shift for residents on coronavirus disease 2019 (COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms) transmission-based precautions (additional measures observed for patients who may be infected with certain infectious agents to prevent infection transmission) for two out of seven sampled residents (Residents 51 and 67).
This deficient practice had the potential to result to undetected signs and symptoms of infection which could lead to serious complications of COVID-19 such as pneumonia (lung inflammation caused by bacterial or viral infection), trouble breathing, and acute respiratory distress syndrome (ARDS - life-threatening lung injury that allows fluid to leak into the lungs).
Findings:
a. A review of Resident 195's Face Sheet indicated the facility admitted the resident on 10/8/2022.
A review of Resident 195's History and Physical (H&P) indicated the resident had a diagnosis of meningoencephalitis (inflammation of the brain and surrounding tissues, usually caused by infection).
A review of Resident 195's Physician Order Report from 10/1/2022 to 10/31/2022 indicated the following orders:
1. On special contact precaution (measure aimed to prevent spread of germs after touching a person or an object the person has touched) and
droplet precaution (measure aimed to prevent spread of germs that are passed through respiratory secretions) every shift.
2. Physical Therapy (PT) for skilled PT every day (QD) seven times a week for two weeks with treatment plan of: therapeutic exercise, therapeutic activities, neuromuscular re-education, gait training, caregiver training, and safety education.
On 10/11/2022 at 10:06 a.m., during an observation, Resident 195 was awake sitting in his wheelchair at his bedside. The resident stated he had just finished physical therapy.
On 10/11/2022 at 10:28 a.m., during a concurrent observation and interview, observed the Director of Rehabilitation (DOR) putting away a cloth gait belt after using it for Resident 195's physical therapy. The DOR verified that it was cloth and not plastic. The DOR stated he sprays it with a disinfectant after use. The DOR stated he is currently using it just for Resident 195 but that he has used it for multiple residents before.
On 10/14/2022 at 10:57 a.m., during an interview, the Infection Prevention Nurse (IP) stated she had already started changing the PT and Restorative Nursing Assistants' (RNAs') cloth gait belts to plastic ones for the purpose of infection control. IP stated the plastic gait belts were easier to disinfect than the cloth ones.
On 10/14/2022 at 1:12 p.m., during an interview, the Director of Nursing (DON) stated it was important to use plastic gait belts as opposed to cloth ones for infection control purposes.
A review of the facility's policy and procedures titled, Infection Control - Enhanced Standard Precautions (ESP - measures observed to safely care for residents who are at increased risk for transmission of multidrug-resistant organisms [MDRO],last updated on 8/23/2022, indicated it is the policy of the facility to utilize enhanced standard precautions (ESP) as outlined by the California Department of Public Health, Joint Infection Prevention and Control Guidelines for California Long-Term Care Facilities.
b. On 10/13/2022 at 11:43 a.m., during an observation and interview, observed Restorative Nursing Assistant 1 (RNA 1) carrying a cloth gait belt. RNA 1 stated she used the gait belt to put around residents' waist to help them stand up during exercises. RNA 1 stated she used it for more than one resident. RNA 1 stated she was assigned to five residents today, and she used the same gait belt for multiple residents. RNA 1 stated she used a disinfecting spray and paper towel to clean the gait belt between residents. RNA 1 stated she used the gait belt for Residents 46, 6, 56, and 88.
A review of Resident 88's Face Sheet indicated the facility admitted the resident on 11/27/2021 with a diagnosis of unspecified fracture (broken bone) of left femur (thigh bone).
A review of Resident 6's Face Sheet indicated the facility originally admitted the resident on 6/6/2019 and readmitted on [DATE] with diagnoses that included difficulty in walking and generalized muscle weakness.
A review of Resident 56's Face Sheet indicated the facility admitted the resident on 11/1/2021 with a diagnosis of difficulty in walking.
A review of Resident 46's Face Sheet indicated the facility originally admitted the resident on 7/25/2022 and readmitted on [DATE] with a diagnosis of sepsis (a potentially life-threatening complication of an infection).
On 10/14/2022 at 10:57 a.m., during an interview, the Infection Prevention Nurse (IP) stated she had already started changing the PT and RNAs' cloth gait belts to plastic ones for the purpose of infection control. IP stated the plastic gait belts were easier to disinfect than the cloth ones.
On 10/14/2022 at 1:12 p.m., during an interview, the Director of Nursing (DON) stated it was important to use plastic gait belts as opposed to cloth ones for infection control purposes.
A review of the facility's policy and procedures titled, Infection Control - Enhanced Standard Precautions, last updated on 8/23/2022, indicated it is the policy of the facility to utilize enhanced standard precautions (ESP) as outlined by the California Department of Public Health and Joint Infection Prevention and Control Guidelines for California Long-Term Care Facilities.
c. A review of Resident 67's Face Sheet indicated the facility admitted the resident on 8/19/2022 and readmitted [DATE] with a diagnosis of encephalopathy (a broad term for any brain disease that alters brain function or structure).
A review of Resident 67's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 9/5/2022, indicated the resident had severely impaired cognitive (thought process) skills for daily decision making and required extensive assistance for bed mobility, transfers, walking in the room and in the corridor, dressing, eating, toilet use, and personal hygiene.
A review of Resident 67's Physician Order Report indicated an order to monitor vital signs two times per shift, every 4 hours.
A review of Resident 67's Medications Administration History (MAH) from 10/1/2022 to 10/12/2022 indicated the licensed nurses did not monitor and document the vital signs on the following dates and times:
1. At 8 a.m. on 10/5/2022
2. At 4 p.m. on 10/6/2022
3. At 8 a.m. on 10/7/2022
4. At 8 a.m. on 10/10/2022
5. At 8 a.m. and 12 p.m. on 10/11/2022
On 10/14/2022 at 10:24 a.m., during a concurrent interview and record review, the Minimum Data Set Nurse (MDSN) verified there were blank spots on Resident 67's MAH where the vital signs should have been documented. MDSN stated that vital signs should have been taken every 4 hours as ordered by the physician, especially if the resident is in the yellow zone (area where residents who were exposed to COVID-19 or are showing symptoms are placed). MDSN stated that because the resident is in the yellow zone, they should be monitored for signs and symptoms of respiratory infection and COVID symptoms.
On 10/14/2022 at 1:12 p.m., during a concurrent interview and record review, the Director of Nursing (DON) verified that vital signs were missing from multiple dates and times for Resident 67.
A review of the facility`s policy and procedures, titled 2019 Novel Coronavirus (COVID-19), indicated in the procedure a criteria for a person under investigation for COVID-19 includes a fever of 100.4 degrees Fahrenheit (°F - scale for measuring temperature) and with severe acute lower respiratory illness (e.g. pneumonia).
d. A review of Resident 51's Face Sheet indicated the facility admitted the resident on 09/22/2022, with diagnoses including chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness, and hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure).
A review of Resident 51's Minimum Data Set (MDS- a resident assessment and care-screening tool) dated 9/28/2022, indicated that Resident 51's cognitive skills (refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making is intact. The MDS also indicated that Resident 51 requires extensive assistance in performing activities of daily living such as dressing, toilet use, and bathing.
On 10/11/2022 at 11:17 a.m., during the facility observation tour, observed Resident 51 sitting on his bed, awake, alert, and oriented to person, place, time and event. Also observed at the bedside table were bottles of condiments labeled as salad dressing, ranch dressing, mayonnaise, and ketchup. During the concurrent observation and interview, Resident 51 stated that he likes to add and mix those condiments to his food and those have been at his table for a couple of days. Resident 51 stated that nobody from the staff had told him or offered to have the condiments refrigerated.
On 10/11/2022 at 11:49 a.m., during an interview, the Dietary Supervisor (DS) stated that per their policy, if there are leftover food at the resident`s bedside, those will be discarded. The DS explained salad dressing, ranch dressing, mayonnaise, and ketchups should not be left at the bedside table and must be refrigerated specially if they are mayonnaise-based. According to the DS, if those condiments' open dates are unknown, have not been refrigerated for a couple of days, and the longer those were kept out of the refrigerator, there is a potential that those condiments were already spoiled and if ingested could cause stomach illness and food poisoning.
A review of the facility`s undated policy and procedures titled, Food for Residents From Outside Sources, indicated that prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, nursing station`s refrigerator or in the residents` personal refrigerator. If opened, the food must be sealed, dated to the date opened and disposed of in 2 days after opening.
e. On 10/13/2022 at 10:32 a.m., during a record review and interview, with Minimum Data Set Nurse (MDSN) indicated that the facility admitted Resident 51 on 9/22/2022. According to MDSN, their COVID-19 protocol for new admission includes placing the resident on transmission-based precaution with vitals signs monitoring per physician`s orders.
A review of Resident 51's admission orders included an order to monitor the vital signs two times per shift from 9/22/2022 to 9/30/2022.
On 10/13/2022 a 10:32 a.m., during a concurrent interview with MDSN and a record review of Resident 51`s Medication Administration History (MAH), the licensed nurses did not monitor and document the vital signs on the following dates and shifts: .
1. 9/25/2022 on 3:00 p.m. to 11:00 p.m. shift - vital signs monitoring was not done for the entire shift.
2. 9/27/2022 on 11:00 p.m. to 7:00 a.m. shift - vital signs monitoring was only done once.
3. 9/28/2022 on 11:00 p.m. to 7:00 a.m. shift - vital signs monitoring was only done once.
4. 9/28/2022 on 7:00 a.m. to 3:00 p.m. shift - vital signs monitoring was not done for the entire shift.
MDSN confirmed the lack of vital signs monitoring per the review of the MAH. According to the MDSN, if vital signs are not monitored per physician`s order, then the nurses would not be able to identify if the resident is showing signs and symptoms of COVID-19 Covid-19 infection and would not be able to intervene promptly and appropriately to prevent worsening of the resident`s medical condition.
A review of the facility`s policy and procedures, titled, 2019 Novel Coronavirus (COVID-19), indicated in the procedure a criteria for a person under investigation for COVID-19 includes a fever of 100.4 degrees Fahrenheit and with severe acute lower respiratory illness (e.g., pneumonia).
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq ft - unit of measure) per resident in four of 18 resident rooms.
The room size for these ...
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Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq ft - unit of measure) per resident in four of 18 resident rooms.
The room size for these rooms had the potential to have inadequate space for resident care and mobility.
Findings:
During the recertification survey from 10/11/2022 to 10/14/2022, the residents residing in the rooms with an application for variance were observed with a sufficient amount of space for residents to move freely inside the rooms. There was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing staff for the residents.
On 10/11/2022, the Administrator submitted the application for the Room Variance for four resident rooms. The room variance letter indicated that these rooms did not meet the 80 square feet per resident requirement per federal regulation. The room waiver request showed the following:
Room #
Square Footage (sq ft)
Bed Capacity
Sq Ft per Resident
1 146 2 73
3 155 2 77.5
9 143 2 71.5
11
151 2 75.5
The minimum requirement for a 2-bed room should be at least 160 sq. ft.
A review of the room variance letter dated 10/11/2022, indicated, There is enough space to provide for each resident's care dignity and privacy and that the rooms are in accordance with the special needs of the residents, and would not have an adverse effect on residents' health and safety or impede the ability of any resident in the rooms to attain his or her highest practicable well-being.
On 10/13/2022 at 9:35 a.m., during an interview, Certified Nursing Assistant 4 (CNA 4) stated she had no issues with the room sizes when it came to resident care. Resident 51, who was assigned to CNA 4, stated the size of his room was not an issue for him, and he had no problems moving around the room.
On 10/13/2022 at 9:47 a.m., during an observation, Certified Nursing Assistant 5 (CNA 5) assisted Resident 141 transfer from her bed to her shower chair (a movable or permanently installed seat for the tub or shower) using her front wheel walker (a walker with two wheels on the front) with no issue. CNA 5 stated she had no problems providing care to residents in spite of the room size.
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 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
- • 38% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 harm violation(s), $63,190 in fines, Payment denial on record. Review inspection reports carefully.
- • 73 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $63,190 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
- • Grade F (15/100). 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 Grand Valley Health's CMS Rating?
CMS assigns GRAND VALLEY HEALTH CARE CENTER an overall rating of 2 out of 5 stars, which is considered 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 Grand Valley Health Staffed?
CMS rates GRAND VALLEY HEALTH CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 38%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Grand Valley Health?
State health inspectors documented 73 deficiencies at GRAND VALLEY HEALTH CARE CENTER during 2022 to 2025. These included: 2 that caused actual resident harm, 68 with potential for harm, and 3 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Grand Valley Health?
GRAND VALLEY HEALTH CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by THE MANDELBAUM FAMILY, a chain that manages multiple nursing homes. With 99 certified beds and approximately 89 residents (about 90% occupancy), it is a smaller facility located in VAN NUYS, California.
How Does Grand Valley Health Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, GRAND VALLEY HEALTH CARE CENTER's overall rating (2 stars) is below the state average of 3.1, staff turnover (38%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Grand Valley Health?
Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.
Is Grand Valley Health Safe?
Based on CMS inspection data, GRAND VALLEY HEALTH CARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-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 Grand Valley Health Stick Around?
GRAND VALLEY HEALTH CARE CENTER has a staff turnover rate of 38%, 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 Grand Valley Health Ever Fined?
GRAND VALLEY HEALTH CARE CENTER has been fined $63,190 across 1 penalty action. This is above the California average of $33,711. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Grand Valley Health on Any Federal Watch List?
GRAND VALLEY HEALTH CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.