VISTA VIEW POST ACUTE
For profit - Limited Liability company
176 Beds
DAVID & FRANK JOHNSON
Data: November 2025
Trust Grade
30/100
#948 of 1155 in CA
Photo by Andrea Cosme
Photo by Vista View Post - Acute
Photo by Andrea Cosme
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Vista View Post Acute has a Trust Grade of F, indicating significant concerns about the quality of care provided, which places it in the bottom tier of nursing homes. It ranks #948 out of 1155 facilities in California, meaning it is in the lower half of all state facilities, and #75 out of 81 in San Diego County, suggesting that there are very few local options that are worse. The facility’s trend is worsening, with issues increasing from 1 in 2024 to 11 in 2025. Staffing at the facility is a relative strength, rated 4 out of 5 stars with a turnover rate of 35%, which is below the state average, indicating that staff members tend to stay longer, creating familiarity with residents. However, there have been serious incidents, including a staff member handling a resident roughly during care, which caused physical pain and fear for the resident, and a failure to maintain an effective quality assurance program to address care issues. While there are some positive aspects, the overall conditions and recent findings raise serious concerns for families considering this facility.
- Trust Score
- F
- In California
- #948/1155
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 35% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 28 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 47 deficiencies on record. Higher than average. Multiple issues found across inspections.
30/100
Bottom 18%
Review needed
1 → 11 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 1 issues
2025: 11 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (35%)
13 points below California average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
2-Star Overall Rating
Below California average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 35%
11pts below California avg (46%)
Typical for the industry
Chain: DAVID & FRANK JOHNSON
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 47 deficiencies on record
1 actual harm
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 F0602
(Tag F0602)
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 safeguard the resident personal property for one of th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to safeguard the resident personal property for one of the two sampled residents (1). As a result, the resident credit card was missing, and a report of unauthorized purchases were charged from Resident 1's credit card.This failure had cause emotional and psychological stress to Resident 1 and may affect the client's trust relationship with the staff.On 7/16/25 at 10 A.M., an unannounced visit at the facility was conducted to investigate a complaint related to a suspicious activity charges on Resident 1's credit card. Resident 1 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (a condition in which bacteria invade and grow in the urinary tract), per the facility's admission Record.On 7/16/25, a review of the minimum data set (MDS- an assessment tool), dated 4/25/25, indicated Resident 1's brief interview for mental status (BIMS - test the resident's cognition status) was 15 (13- 15 meant intact cognition).A review of the Interdisciplinary Team Care Conference (IDT -a group of healthcare professionals from various disciplines who collaborate to provide comprehensive patient care), dated 7/11/25, indicated, .IDT met to discuss an incident involving alleged financial abuse. A report was received from the resident assigned resource counselor regarding an unusual charge on Resident 1's credit card. The resident had given her credit card to a few of the CNA's (certified nursing assistant) to get snacks from the vending machine.On 7/16/25 at 10:50 A.M., an observation and an interview with Resident 1 was conducted in her room. Resident 1 was lying in her bed with the head of the bed elevated. Resident 1 stated she would give her credit card to a CNA to buy soda or snacks from the vending machine. Resident 1 stated she could not remember if her credit card was missing but a staff member found her credit card in the nightstand drawer. Resident 1 stated she could not remember the name or identify the staff member.On 7/16/25 at 11:05 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 1 would ask CNA 1 to get her soda or snacks from the vending machine, and Resident 1 would give her credit card to CNA 1. CNA 1 stated after buying snacks, she would return the credit card to Resident 1.On 7/16/25 at 11:26 A.M., an interview was conducted with the Social Service Director (SSD). The SSD stated on 6/23/25, Resident 1 came to her office and reported that her credit card was missing. The SSD and another staff member searched Resident 1's room and found her credit card in the nightstand drawer. The SSD stated, on 7/9/25, Resident 1 and the resident's resource counselor spoke to the SSD to discuss and review the list of unusual transactions received from the credit card company. The unusual transactions charged to Resident 1's card indicated:- 5/31/25 - The Grateful Head Glass - $50.00- 5/31/25 - The Grateful Head Glass - $102.83- 6/1/25 - The Grateful Head Glass - $102.84- 6/6/25 - [NAME] (Gas Station) - $6.30-6/6/25 - The Grateful Head Glass - $97.43-6//6/25 - The Grateful Head Glass - $ 97.43- 6/18/25 - The Grateful Head Glass - $97.43- 6/21/25 - Starbucks - $ 14.40On 7/16/25 at 11:48 A.M., a telephone interview was conducted with CNA 2. CNA 2 stated she was assigned to Resident 1 and familiar with Resident 1's care. CNA 2 stated Resident 1 would give her credit card to CNA 2 to get snacks from the vending machine then return back the credit card to Resident 1 after buying the snacks. CNA 2 stated in the month of June 2025, she forgot to return back the credit card to Resident 1. CNA 2 stated she was off for two days and had Resident 1's credit card with her. CNA 2 further stated she did not inform the facility and Resident 1 that the credit card was in her possession. CNA 2 stated she might have accidentally used Resident 1's credit card for purchase.On 7/16/25 at 12:18 P.M., an interview and joint review of the CNA 2's employee file review was conducted with the Director of Staff Development (DSD). The DSD stated on orientation; staff received training on theft and loss. The DSD could not find the signed acknowledgement form from CNA 2.On 7/16/25 at 12:45 P.M., an interview was conducted with the Administrator (ADM). The ADM stated the investigation started on 7/9/25 when Resident 1 and Resident 1's resource counselor reported an unusual charges in Resident 1's credit card. The ADM stated staff should not have taken residents' credit cards. Staff should accompany residents if they needed snacks in the vending machine. The ADM stated the facility reimbursed Resident 1's credit card charges. The ADM stated both CNA 1 and CNA 2 were interviewed separately during their investigation process. The ADM stated both CNA1 and CNA 2 acknowledged they accepted Resident 1's credit card to buy snacks from the facility's vending machine and would return the credit card back to Resident 1. The ADM stated he was not aware of staff accepting credit cards from the residents to buy snacks from the facility's vending machine. In addition, the ADM stated during an interview with CNA 1, CNA 1 denied knowing the place called Grateful Head Glass. CNA 1 stated she only used Resident 1's credit card to buy snacks from the facility's vending machine. The ADM stated during interview with CNA 2, CNA 2 acknowledged that she knew the Grateful Head Glass place and would purchase items from the Grateful Head Glass place.On 7/29/25 at 3:08 P.M., a telephone interview with Resident 1's resource counselor was conducted. The resource counselor (RC) stated she was assisting Resident 1 with her finances and noticed the unusual charges in Resident 1 credit card. The RC stated Resident 1 and the RC, contacted the credit card company and obtained an itemized list of unauthorized transactions. The list of charges in Resident 1's credit card was reviewed. The RC stated Resident 1 did not leave the facility since admission. The RC also stated Resident 1 used her card for snacks at the facility's vending machine. The RC stated she discussed and reviewed the itemized list of unusual charges in Resident 1's credit card with the facility social worker.On 7/31/25 at 8:50 A.M., an interview and record review were conducted with the SSD. The SSD stated the copy of the itemized transaction in Resident 1's credit card was provided by Resident 1 and Resident 1's resource counselor. The SSD stated Resident 1 used her credit card for the vending machine. The SSD further stated Resident 1 had not left the facility since admission.On 7/31/25 at 9:10 A.M., an interview and review of the itemized list of transactions in her credit card was conducted with Resident 1. Resident 1 stated she did not know the Grateful Head Glass, the [NAME], Starbucks charges in her card. Resident 1 stated she used her card for the vending machine for snacks. Resident 1 was upset about the unusual charges in her credit card. She stated she got a new credit card, and kept in the social worker's office.A review of the facility's policy and procedure titled, Theft and Loss of Resident Personal Property, dated 7/16/13, indicated . facility shall make reasonable efforts to protect the personal property of residents in a manner that will comply with regulatory requirements .
Jun 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 respect and dignity was provided to one of three sampled res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure respect and dignity was provided to one of three sampled residents (Resident 2) when a certified nursing assistant (CNA) opened resident's drawer without permission and said inappropriate words towards Resident 2.
This failure had the potential to make residents feel disrespected and may have resulted in diminished quality of life and lower self-esteem.
Findings:
Resident 2 was admitted on [DATE], with diagnoses which included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and bipolar disorder (a mental health condition that causes extreme mood swings), per the facility's admission Record.
A review of Resident 2's minimum data set (MDS- an assessment tool), dated 4/16/25, indicated, her brief interview for mental status (BIMS - test the resident's cognition status) was 15 (13- 15 meant intact cognition).
On 5/28/25 at 12:31 P.M., an interview was conducted with the Director of Social Services (DSS). The DSS stated a text message was received from Licensed Nurse (LN) 4 regarding the incident with Resident 2. The DSS stated on 5/19/25, an interview with Resident 2 was conducted. Resident 2 told DSS that CNA 2 went to Resident 2's room looking for diapers, opened her (resident) drawer without asking permission. Resident 2 stated while she was reporting the incident to LN 4 in the nursing station, CNA 2 told Resident 2 Shut the f** up. The DSS stated Resident 2 was upset with the incident but later calmed down.
On 5/28/25 at 1:43 P.M., an interview was conducted with Resident 2. Resident 2 stated on 5/19/25 around 5 A.M., she was awake in her bed and was in her phone when CNA 2 came inside the room. CNA 2 opened her drawers looking for diapers without asking permission. Resident 2 stated she asked CNA 2 to stop rummaging her drawers, but CNA 2 responded You don't own these diapers. Resident 2 stated she went to the nursing station and reported to LN 4 regarding the incident with CNA 2. Resident 2 stated, while she was talking to LN 4, CNA 2 screamed at her and told her to shut the f** up.
On 5/28/25 at 2:14 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated staff were trained on resident rights and different kinds of abuse, and who to report abuse at least annually. The DSD stated staff should treat residents with respect and dignity.
On 6/9/25 at 7:34 A.M., a telephone interview was conducted with Licensed Nurse (LN) 4. LN 4 stated she worked on the date of the incident. LN 4 stated Resident 2 was alert and oriented, and able to make her needs known. LN 4 stated she was coming out in one of the rooms in front of the nursing station when she saw Resident 2 and CNA 2 in front of the nursing station and heard CNA 2 saying shut the f** up . Resident 2 told LN 4 that CNA 2 went inside her room and started opening her drawers looking for diapers without asking her permission and followed me in the nursing station and said the word shut the f** up. LN 4 stated CNA 2 was not assigned to Resident 2 on the date of the incident. LN 4 stated CNA 2 should have gone to the supply room for diaper instead of going through the resident's supply in resident's room. LN 4 further stated CNA 2 should have not said those inappropriate words to the resident at any time.
On 6/10/25 at 4:03 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectation for her staff was to respect residents' privacy and treated with dignity. Staff should asked permission from the resident when opening their personal belongings and not to use vulgar words.
A review of the facility's policy and procedures (P & P) titled, Resident Rights, dated 12/19/22, indicated . the resident has the right to a dignified existence, self -determination, and communication .4. Respect and Dignity . the resident has the right to be treated with respect and dignity .
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 F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify and confirmed bed hold notice to the resident's family repre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify and confirmed bed hold notice to the resident's family representative upon transfer to an acute care facility (hospital) for one of three sampled residents (Resident 1).
This failure resulted in Resident 1' s family representative confusion related to bed hold payment.
Findings:
Resident 1 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a common lung disease causing restricted airflow and breathing problems), per the facility's admission Record.
A review of Resident 1's Bed Hold Notification Informed Consent Form was conducted. There was no indication of Resident 1's family representative was notified and confirmed the bed hold when Resident 1 was transferred to an acute hospital.
On 5/28/25 at 1 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated nursing staff, or social services would follow up with the family representative to offer bed hold when a resident was transferred to an acute care facility.
On 6/9/25 at 9:32 A.M., a telephone interview was conducted with the Business Office Manager (BOM). The BOM stated nursing staff would contact the family to notify and confirmed bed hold when a resident transferred to an acute care facility. The BOM stated residents were not placed on bed hold right away. The nursing staff would notify and confirm with the family representative that they would like a bed hold.
On 6/9/25 at 9:55 A.M., a telephone interview was conducted with the DON. The DON stated the nurse would contact the family representative to confirm and verify the bed hold. The DON stated nursing staff should have documented the notification and confirmation from the family representative.
On 6/9/25 at 5 P.M., a telephone interview was conducted with Licensed Nurse (LN) 1. LN 1 stated when Resident 1 was transferred to an acute care facility on 1/22/25, he did not verify and confirmed the bed hold with the family representative. LN 1 stated family should be notified and verified bed hold with the resident or family representative and documented in the form.
On 6/10/25 at 7:27 A.M., a telephone interview was conducted with LN 2. LN 2 stated she did not follow up with Resident 1's family representative to offer and confirmed bed hold when Resident 1 was transferred to an acute care facility on 1/22/25. LN 2 stated when the family confirmed the bed hold, it should have been documented in the bed hold form and or progress note.
On 6/10/25 at 3:53 P.M., a telephone interview was conducted with the Social Service Director (SSD). The SSD stated nursing was responsible for contacting and following up with the resident and or family representative to offer bed hold when a resident was transferred out to an acute care facility.
On 6/10/25 at 4:19 P.M., an interview was conducted with the DON. The DON stated Resident 1's Bed Hold Informed Consent Form did not have any documentation related to the notification, confirmation of transfer and bed hold provision. The DON stated the nursing staff should have completed and documented in the form and in the progress notes when Resident 1 was transferred out to an acute care facility.
A review of the facility's policy and procedures (P&P), titled Bed Hold Notice, dated 12/19/22, indicated . at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and /or the resident representative a written notice which specifies the duration the bed hold policy .2. In the event of an emergency transfers of a resident, the facility will provide within 24 hours written notice of the facility's bed hold policies .
May 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to maintain the blinds in 5 resident rooms ( Ro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to maintain the blinds in 5 resident rooms ( Rooms 107, 112, 130, 131, and 138) of 30 resident rooms on the first floor of the facility in good condition.
Findings included:
A facility policy titled, Safe and Homelike Environment, dated 12/19/2022, indicated, 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
During an observation on 05/01/2025 at 9:08 AM, room [ROOM NUMBER], located on the first floor, had horizontal window blinds in place with 22 missing blind slats (individual horizontal or vertical strips of material that made up the structure of the blind). The missing window slats created an open area that measured approximately four and one half feet by eight inches that potentially exposed residents to public view.
During an observation on 05/01/2025 at 8:59 AM, room [ROOM NUMBER] had vertical blinds with 13 missing slats.
During an observation on 05/01/2025 at 8:58 AM, room [ROOM NUMBER] had horizontal blinds that covered a sliding glass door with a view into a center courtyard, and two slats were missing from the blinds.
During an observation on 05/01/2025 at 8:57 AM, room [ROOM NUMBER] had horizontal blinds that covered a sliding glass door with a view into a center courtyard. One slat was missing from the blinds, and one slat was noted lying on the floor.
During an observation on 05/01/2025 at 9:28 AM, room [ROOM NUMBER] had vertical blinds that covered a sliding door, and the blinds were missing six slats which caused a gap of approximately one foot by seven feet.
During a concurrent observation and interview on 05/01/2025 at 9:45 AM, Certified Nursing Assistant (CNA) #3 stated if something were broken in a resident's room she would report it in the maintenance log, and she demonstrated where the maintenance log was located at the nurses' station. CNA #3 confirmed by way of observation the broken blinds in room [ROOM NUMBER] and stated she had not noticed the broken blinds before. CNA #3 entered room [ROOM NUMBER] and stated she had not noticed the two slats missing, and stated it should be reported. CNA #3 entered room [ROOM NUMBER] and stated she had been aware of the broken blinds for more than a few weeks but had not reported it.
During a concurrent observation and interview on 05/01/2025 at 10:03 AM, Registered Nurse (RN) #4 stated if there was a broken but not harmful item in a resident's room she would put it in the logbook. RN #4 stated she had not reported anything recently, and she had not seen anything broken. RN #4 revealed missing blinds was something she would report to the maintenance department. RN #4 entered room [ROOM NUMBER] and stated she observed 13 missing blind slats. RN #4 entered room [ROOM NUMBER] and stated there was two missing blind slats. RN #4 entered room [ROOM NUMBER] and stated she counted six missing blind slats, and that was something she would report immediately.
During a concurrent observation and interview on 05/01/2025 at 10:27 AM, the Maintenance Director stated that when a staff member observed broken items in a resident's room the staff member was expected to log the item in the maintenance book. The Maintenance Director stated he had not received a maintenance request within the last couple of weeks to repair blinds. The Maintenance Director entered room [ROOM NUMBER] and stated the 13 missing blind slats was a concern because it allowed more heat to come into the room, and the apartment building behind the facility was about 200 feet away with a clear line of sight into the room. The Maintenance Director entered room [ROOM NUMBER] and noted the two missing blind slats. The Maintenance Director entered room [ROOM NUMBER] and noted one slat on the ground. The Maintenance Director stated the six blind slats missing in room [ROOM NUMBER] needed to be repaired.
During an interview on 05/01/2025 at 12:15 PM, the Director of Nursing (DON) stated that when a clinical staff member identified a maintenance issue, the staff typically called the Maintenance Director and the leadership team if the issue was an emergency. The DON stated the clinical staff sent out a text message when something was found broken. The DON stated if the staff member was a nursing assistant they told the nursing supervisor, and the supervisor would notify the team. The DON stated there was a maintenance log to document when an issue was identified. The DON stated maintenance was expected to follow-up on the concerns in the maintenance book.
During an interview on 05/01/2025 at 12:44 PM, the Administrator stated staff should place a maintenance issue on the maintenance log, which was checked by the Maintenance Director. The Administrator stated after the repair was made he checked the log against the repair to verify completion. The Administrator stated if something was broken it needed to be fixed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident ...
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Based on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASARR) when the resident was diagnosed with a new mental illness diagnosis for 1 (Resident #104) of 2 sampled residents reviewed for PASARR.
Findings included:
A facility policy titled, Resident Assessment - Coordination with PASARR Program, revised 12/18/2023, revealed, This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy specified, 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.
An admission Record revealed the facility admitted Resident #104 on 02/06/2023. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction. The admission Record indicated the resident received a diagnosis of depression on 09/26/2024 and bipolar disorder on 11/26/2024.
A quarterly Minimum Data Base (MDS), with an Assessment Reference Date (ARD) of 03/25/2025, revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses that included depression and bipolar disorder.
Resident #104's Care Plan Report included a focus area initiated 05/07/2024, that indicated the resident used an antidepressant medication related to a diagnosis of depression.
Resident #104's medical record revealed no evidence to indicate a level II PASARR was resubmitted after the resident was diagnosed with depression on 09/26/2024 or bipolar disorder on 11/26/2024.
During an interview on 05/01/2025 at 9:00 AM, the Assistant Director of Nursing (ADON) stated she was one of the facility leadership staff who was responsible for PASARRs. The ADON stated that when a new mental illness diagnosis was added to a resident's record, a PASARR was completed and submitted to the state. The ADON stated the Social Services Director (SSD) and the Director of Health Information also had access to the system, and any one of them could submit a PASARR. Per the ADON, Resident #104 had a diagnosis of bipolar disorder, and a new PASARR should have been submitted.
During an interview on 05/01/2025 at 9:32 AM, the SSD stated that when a new mental illness diagnosis was added to a resident record, a PASARR should be completed. According to the SSD, the ADON was responsible for submitting PASARRs. The SSD reviewed Resident #104's diagnoses list and stated she expected a PASARR to be resubmitted when the resident's bipolar disorder diagnosis was added.
During an interview on 05/01/2025 at 11:43 AM, the Director of Nursing (DON) stated if another PASARR was required, the ADON submitted the screening. The DON stated a new mental illness diagnosis required a PASARR to be resubmitted.
During an interview on 05/01/2025 at 11:26 AM, the Administrator stated the facility followed state and federal regulations. The Administrator stated he expected PASARR screenings to be submitted following the addition of a new mental illness diagnosis. The Administrator stated the ADON took the lead on the PASARR process; however, he tried to get several people involved so that alternate staff were always available to address PASARR concerns.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on interview, record review, and facility policy review, the facility failed to resubmit a level I preadmission screening and resident review (PASARR) to the appropriate state-designated authori...
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Based on interview, record review, and facility policy review, the facility failed to resubmit a level I preadmission screening and resident review (PASARR) to the appropriate state-designated authority for 1 (Resident #81) of 2 sampled residents reviewed for PASARR.
Findings included:
A facility policy titled, Resident Assessment - Coordination with PASARR Program, revised 12/18/2023, revealed, This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.
An admission Record indicated the facility readmitted Resident #81 on 12/16/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, anxiety disorder, and depression.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/28/2025, revealed Resident #81 had a Staff Assessment for Mental Status (SAMS) that indicated the resident was moderately impaired in cognitive skills for daily decision making. The MDS revealed Resident #81 had active diagnoses to include anxiety disorder, depression, and schizophrenia.
Resident #81's Care Plan Report included a focus areas initiated 02/23/2022, that indicated the resident used anti-anxiety medications related to a diagnosis of anxiety disorder. The Care Plan Report also included a focus area initiated 09/27/2023, that indicated the resident used antidepressant medication related to a diagnosis of depression. The Care Plan Report included a focus area initiated 02/11/2025, that indicated the resident had a diagnosis of schizophrenia, including symptoms such as delusions, hallucinations, disorganized speech, disorganized behavior, and negative behaviors.
A letter from the California Department of Health Care Services dated 12/27/2024, revealed a level II mental health evaluation was required for Resident #81 due to the resident's serious mental illness.
A letter from the California Department of Health Care Services dated 12/27/2024, revealed a level II evaluation was unable to be completed for Resident #81's serious mental illness due to the facility staff being unresponsive on two or more separate communication attempts within 48 hours. Per the letter, the facility must resubmit a new Level I Screening.
During an interview on 05/01/2025 at 8:56 AM, the Assistant Director of Nursing (ADON) stated she was in charge of the PASARR program and had access to the PASARR portal. The ADON stated she had not seen the notice from the state about not being able to reach the facility. According to the ADON, Resident #81's PASARR should have been resubmitted when the facility received the notice.
During an interview on 05/01/2025 at 11:43 AM, the Director of Nursing (DON) stated the ADON oversaw the PASARR screenings in the facility. Per the DON, if a level I PASARR was positive and the facility could not be reached for further information, she expected the screening to be resubmitted. The DON stated Resident #81's PASARR should have been resubmitted for evaluation and recommendations from the state office.
During an interview on 05/01/2025 at 11:25 AM, the Administrator stated that he expected the facility to follow the state and federal requirements for reviewing and submitting PASARR screenings. He stated that if a resident had a positive level I, he expected a letter of determination to be in the resident's record and a follow up completed. According to the Administrator, the ADON was the lead for PASARRs, and multiple facility nurses had access as well. The Administrator stated Resident #81's PASARR should have been resubmitted to the PASARR office when the letter was received indicating communication could not be made with the facility.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on interview, document review, and facility policy review, the facility failed to post the actual hours worked by staff directly responsible for resident care for 12 of 12 shifts reviewed. This ...
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Based on interview, document review, and facility policy review, the facility failed to post the actual hours worked by staff directly responsible for resident care for 12 of 12 shifts reviewed. This deficient practice had the potential to affect all residents who currently resided in the facility.
Findings included:
A facility policy titled, Nurse Staffing Posting Information, dated 03/10/2025, indicated, It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides.
The facility Nurse Staff Projection, documents dated 04/25/2025, 04/27/2025, 04/28/2025, and 04/29/2025, revealed the documents did not indicate the actual hours worked for all three shifts each day for the staff directly responsible for resident care.
During an interview on 05/01/2025 at 8:54 AM. the Scheduler stated he had been the staffing coordinator for the past two years and was responsible for the posting of nurse staffing data. The Scheduler stated he tried to maintain the nurse staffing records but sometimes forgot to print or post them.
During an interview on 05/01/2025 at 9:49 AM, the Director of Staff Development (DSD) stated she worked closely with the Scheduler to provide oversight. The DSD stated she did not update the nurse staffing data sheets on 04/25/2025, 04/27/2025, 04/28/2025, or 04/29/2025 to show the actual hours worked by the staff. The DSD stated she expected 100 percent compliance with the data for nurse staffing postings.
During an interview on 05/01/2025 at 10:48 AM, the Director of Nursing stated she expected the nurse staffing data to be adjusted as needed for call outs, have the appropriate disciplines included in the count, and to be correct.
During an interview on 05/01/2025 at 11:02 AM, the Administrator stated the nurse staffing postings should be accurate. The Administrator stated that staff should be able to go back and adjust staffing data based on staffing changes.
Apr 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
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 choice was offered to accomodate a preference for a shower f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure choice was offered to accomodate a preference for a shower for one resident (Resident 304).
This failure had the potential to cause psychological harm to Resident 304.
Findings.
Resident 304 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis (the spaces inside the bones of the spine gets too small) and Discogenic Pain (localized back pain that worsens with activities that increase pressure on the spine).
On 4/7/25 at 10:20 A.M., an interview with Certified Nursing Assistant (CNA) CNA 1 was conducted. CNA 1 stated on 3/21/25 in the morning, she and CNA 2 went into Resident 304 ' s room and told Resident 304 she was getting a shower then immediately transferred from the bed to the shower. CNA 1 stated during transfer, Resident 304 had urinated on herself and bowel movement. CNA 1 stated they had to put Resident 304 back to bed to clean her up, then place in the Hoyer lift to transfer Resident 304 to the shower chair.
On 4/7/25 at 11:20 A.M., an interview with Resident 305 was conducted. Resident 305 stated she had been Resident 304 ' s roommate since she got admitted to the facility. Resident 305 stated she seen and witnessed the incident on 3/21/25 when Resident 304 was to have a shower that day. Resident 305 stated she had seen Resident 304 yanked out of her bed and hoist Resident 304 up from the bed.
A review of Resident 305 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/21/25 indicated Resident 305 ' s brief interview for mental status (BIMS) score was 14 which meant Resident 305 ' s cognition (thought process) was intact.
On 4/7/25 at 11:35 A.M., an interview with Resident 304 was conducted. Resident 304 stated CNA 1 and CNA 2 went into her room and stated you are getting a shower. Resident 304 stated she was not given a choice if she wanted the shower or not. Resident 304 stated she felt bad when she started peeing and pooping on herself while being transferred to the shower chair with both CNA 1 and CNA 2. Resident 304 stated CNA 1 and CNA 2 were both arguing about how to operate the Hoyer lift and that made Resident 304 upset and worried. Resident 304 stated after the incident, a psychiatrist came to see her to discussed and offered anti-anxiety medication, but Resident 304 refused. Resident 304 stated it was her first time in a convalescent home and did not know what to expect.
A review of Resident 304 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/27/25 indicated, Resident 304 ' s brief interview for mental status (BIMS) score was 14 which meant Resident 304 ' s cognition (thought process) was intact.
A review of Resident 304's MDS dated [DATE], section E indicated, Resident 304 had 0 behaviors.
On 4/7/25 at 12:20 P.M., an interview with CNA 3 was conducted. CNA 3 stated Resident 304 was alert and oriented and would stand and transfer from the wheelchair to her bed with minimal assistance. CNA 3 stated Resident 304 would just complain of pain in her back at times. CNA 3 stated it was important to explain to Resident 304 what was being done prior to proceeding with her care.
An interview on 4/7/25 at 12:35 P.M., with the Social Service Director (SSD) was conducted. The SSD stated the facility had a meeting with Resident 304 ' s son to discuss his complaint regarding staff being rough to his mother. Resident 304 ' s son stated his mother, Resident 304 was forced to get a shower and was naked while on a device on 3/21/25.
An interview on 4/7/25 at 1:45 P.M., with Licensed Nurse (LN) 1 was conducted. LN 1 stated Resident 304 was alert and oriented x4, and did not have any behaviors. LN 1 stated Resident 304 was cooperative with her care and treatment, and was on routine Tylenol (medication for pain) for her back pain.
An interview on 4/7/25 at 2:30 P.M., with the Assistant Director of Nursing ( ADON) was conducted. The ADON stated it was important to let Resident 304 have a choice or preference regarding her shower or any care to be provided by the staff. The ADON stated the facility will have more positive outcome if Resident 304 was made aware and given a choice before proceeding with the shower. The ADON stated it was important to respect resident ' s wishes and to treat them with dignity and respect.
A review of the facility ' s policy dated 12/10/2022 titled, Resident Rights indicated .2.Planning & implementing care .c. the right to be informed in advance, of the care to be furnished .e. the right to refuse , and /or discontinue treatment , to participate in or refuse to participate .3.Policy explanation & compliance guidelines .#11 the facility will ensure that all direct staff .are educated on the rights of residents .5.a. the resident has the right to choose activities, schedules .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure privacy was maintained for one of one resident (Resident 304...
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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 privacy was maintained for one of one resident (Resident 304) when the two CNAs (1, 2) left Resident 304's naked body exposed during the delivery of care.
This failure violated Resident 304's right to dignity and privacy.
Findings.
Resident 304 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis (the spaces inside the bones of the spine gets too small) and Discogenic Pain (localized back pain that worsens with activities that increase pressure on the spine).
An interview on 4/7/25 at 11:20 A.M., with Resident 305 was conducted. Resident 305 stated she had been Resident 304 ' s roommate since she got admitted to the facility. Resident 305 stated she had seen and witnessed the incident on 3/21/25 when Resident 304 was to have a shower that day. Resident 305 stated she had seen Resident 304 yanked out of her bed, hoist Resident 304 up, and was naked.
Resident 305 stated Resident 304 was in the Hoyer Lift hanging from the ceiling while being transferred to the shower chair by CNA 1 and CNA 2. Resident 305 stated there was no privacy provided during the delivery of care allowing anyone to view Resident 304's naked body since the curtain between them was pulled all the way back.
A review of Resident 305 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/21/25 indicated Resident 305 ' s brief interview for mental status (BIMS) score was 14 which meant Resident 305 ' s cognition (thought process) was intact.
On 4/7/25 at 11:35 A.M., an interview with Resident 304 was conducted. Resident 304 stated CNA 1 and CNA 2 went into her room and stated you are getting a shower. Resident 304 stated she was not given a choice if she wanted the shower or not. Resident 304 stated she felt bad when she started peeing and pooping on herself while being transferred to the shower chair with both CNA 1 and CNA 2. Resident 304 stated CNA 1 and CNA 2 were both arguing about how to operate the Hoyer lift and that made Resident 304 upset and worried. Resident 304 stated after the incident, a psychiatrist came to see her to discussed and offered anti-anxiety medication, but Resident 304 refused. Resident 304 stated it was her first time in a convalescent home and did not know what to expect.
A review of Resident 304 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/27/25 indicated Resident 304 ' s brief interview for mental status (BIMS) score was 14 which meant Resident 304 ' s cognition (thought process) was intact.
A review of Resident 304's MDS dated [DATE], section E indicated Resident 304 had 0 behaviors.
An interview on 4/7/25 at 12:35 P.M., with the Social Service Director (SSD) was conducted. The SSD stated the facility had a meeting with Resident 304 ' s son to discuss his complaint regarding staff being rough to his mother. Resident 304 ' s son stated his mother, Resident 304 was forced to get a shower and was naked while on a device on 3/21/25.
An interview on 4/7/25 at 2:30 P.M., with the Assistant Director of Nursing ( ADON) was conducted. The ADON stated the staff should have provided privacy when performing any resident's care to ensure residents privacy were provided and their dignity were respected.
A review of the facility ' s policy dated 12/10/2022 titled, Resident Rights indicated .4.Respect & dignity .c.The right to reside & receive services in the facility with reasonable accommodation of needs and preference .5. Self-determination .5.a. the resident has the right to choose activities, schedules . b.The resident has the right to make choices about aspects of his or her life . Policy explaination and Compliance Guidelines .11. the facility will ensure that all direct staff .are educated on the rights of residents .
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
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the licensed nurses (LN) had specific competencies and train...
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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 licensed nurses (LN) had specific competencies and training related to Central Venous Catheter site (CVC- a soft plastic tube inserted into a vein to provide vascular access for hemodialysis [a treatment that filters waste and excess fluid from the blood of people whose kidneys were not functioning properly] for 5 of 7 licensed nurses (LN).
This failure had the potential to result in inaccurate assessment and delayed care and treatment of a resident with a CVC line.
Findings:
Resident 1 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (ESRD- kidney failure) per the admission Record.
On 8/22/24 at 4:30 P.M., an interview was conducted with LN 3. LN 3 stated that to assess the CVC site, LNs had to examine the site and document the signs and symptoms of infection and the condition of the dressing. LN 3 further stated there would be no bruit [a whooshing sound] that happens when the blood flows to the body and trill [vibration over the blood vessel]. LN 3 stated the bruit and trill would be heard and felt for residents with AVF (arteriovascular fistula- a surgical connection between an artery and a vein).
A review of Resident 1's Dialysis Communication Form was conducted. Under the Dialysis Center Information section, dated 7/24/24 through 8/7/24, Resident 1 had a CVC line in the left chest that the dialysis center used during dialysis treatment.
On 7/24/24, 7/29/24, and 8/3/24, under the post-dialysis information [assessment performed by the facility], LN 1 documented the presence of bruit and trill.
On 7/26/24, under the post-dialysis information section, LN 6 documented the catheter was patent (no obstruction), and bruit and trill were present. LN 6 was a licensed vocational nurse (LVN).
On 7/31/24, under the post-dialysis information section, LN 4 documented the presence of bruit and trill.
On 8/5/24, under the post-dialysis information section, LN 6 documented the presence of bruit and trill.
On 8/7/24, under the post-dialysis information section, LN 5 documented the presence of bruit and trill.
On 8/22/24 at 3:16 P.M., an interview was conducted with LN 1. LN 1 stated she had cared for Resident 1 and did not have proper training for CVC for hemodialysis.
On 8/22/24 at 4 P.M., an interview was conducted with LN 2. LN 2 stated there was no formal training about the CVC for hemodialysis. Per LN 2, It was verbal instructions during endorsement (report).
On 8/28/24 at 4:30 P.M., an interview was conducted with LN 4. LN 4 stated he did not have formal training for CVC for hemodialysis.
On 8/29/24 at 12:30 P.M., an interview was conducted with LN 5. LN 5 stated he had formal training in CVC assessment. However, on 8/7/24, many things were happening, and human error occurred. LN 5 further stated he documented check marks on the bruit and trill (dialysis communication form) without assessing the site, and should not have.
On 8/29/24 at 1:15 P.M., an interview was conducted with LN 6. LN 6 stated she watched many videos upon hire and could not recall if one was about CVC assessment and care. LN 6 stated she should not have documented that the catheter was patent because it was beyond her scope (as a LVN) to check the CVC line's patency, and she was not allowed to touch the CVC. LN 6 further stated she assumed the line was patent because Resident 1 returned from hemodialysis.
On 9/3/24 at 4:40 P.M., an interview was conducted with the Director of Nursing (DON). The DON acknowledged the LNs should have competencies and training (for CVC), and stated assessment for the CVC site should have been monitored for bleeding, signs and symptoms of infection, and if the dressing was intact.
The facility could not provide a policy and procedure for CVC care, training, and skills checks for the CVC line.
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
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 prescribed medications were completely administered to one of three residents (Resident 1).
This had the potential to...
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Based on observation, interview, and record review, the facility failed to ensure prescribed medications were completely administered to one of three residents (Resident 1).
This had the potential to affect the goal of treatment and put Resident 1 ' s health and safety at risk.
Findings:
An observation and interview was conducted on 4/26/23 at 12:50 P.M. inside Resident 1 ' s room. A white pill was inside a medicine cup lying on the bedside table. Resident 1 identified the white pill was her Baclofen (brand name of a pain medication). Resident 1 stated she did not know there was one white pill left in the medication cup and further stated she did not get the three tablets scheduled at 8:00 A.M.
A review of Resident 1 ' s electronic medication administration record (EMAR, electronic version of medications received by a resident) dated, April 26, 2023 indicated, Baclofen (brand name, pain medication) Oral Tablet 5 milligrams (mg, unit of measurement). Give 3 tablets by mouth four times a day for pain management.
A review of Resident 1 ' s minimum data set (MDS, an assessment tool) dated 4/10/23 indicated, the BIMS (brief interview for mental status)score was 14 out of 15 which meant, she was cognitively intact.
On 4/26/23 at 12:55 P.M., an interview with the licensed nurse (LN A) was conducted. LN A acknowledged the above observation and stated she administered the medications at 8:00 A.M. LN A further stated Resident 1 should have received three tablets of Baclofen.
An interview was conducted with the charge nurse (CN) on 4/26/23 at 1:00 P.M. The CN stated licensed nurses should wait and verify resident ' s medications were safely and completely administered before leaving the resident.
On 4/26/23 at 1:25 P.M., an interview was conducted with the director of nursing (DON). The DON stated all LNs should observe the residents while taking prescribed medications to ensure the residents were able to take correct dose.
Review of the facility ' s policy titled Medication Administration dated 9/2/22, indicated Observe resident consumption of medication
Jun 2021
23 deficiencies
1 Harm
SERIOUS
(G)
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 ensure one of 30 sampled residents (Resident 75) reviewed for abuse...
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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 30 sampled residents (Resident 75) reviewed for abuse and neglect, was free from physical and verbal abuse and neglect when:
1. Certified nursing assistant (CNA) 1 handled Resident 75 in a rough manner during incontinence (an inability to control the release of urine or feces) care. Furthermore, CNA 1 did not stop providing care when Resident 75 requested for her to stop.
2. CNA 1 told Resident 75, No one likes you here. You complain too much, and called the resident a racist.
3. CNA 1 did not clean Resident 75 after an incontinence episode as per the resident's request.
As a result of these failures, Resident 75 experienced physical pain and was in fear of CNA 1. The day after the incident with CNA 1 (6/17/21), Resident 75 felt upset and stressed, lacked her usual appetite, was nauseous, and vomited.
Findings:
A review of Resident 75's admission Record dated 6/18/21, indicated the resident was readmitted to the facility on [DATE], and had the following diagnoses: Age-related osteoporosis (brittle bones), osteoarthritis (wearing down of the protective tissue at the end of the joints) of the right hip, spondylosis (osteoarthritis of the spinal disks) of the cervical (neck) region, cervicalgia (neck pain), and sciatica (sciatic nerve pain [nerve along the buttock and leg region]), right side.
On 6/18/21 at 9:06 A.M., an observation and interview was conducted with Resident 75 inside the resident's room. Resident 75 was in bed with approximately 8 pillows in total that were arranged underneath the resident's arms, legs, between her legs, and behind her head and neck. Resident 75 wore a hospital gown and the lower half of her body was covered with a sheet. Resident 75 stated she had had an incident with her assigned CNA (CNA 1) the other night on 6/16/21. Resident 75 stated she had a specific way she preferred to be cleaned after an incontinence episode and that her personal hygiene routine took time. Resident 75 stated she saw CNA 1 around 4 P.M. on 6/16/21, and they both agreed upon 9:30 P.M. as the time to change her incontinence brief. Resident 75 stated CNA 1 had seemed nice at that time. Resident 75 stated CNA 1 arrived to change her after 10 P.M. Resident 75 stated she had asked CNA 1 what took her so long to arrive, and CNA 1 told her that she had to care for other residents. Resident 75 stated CNA 1 seemed to have been in a bad mood. Resident 75 stated CNA 1 began to yank the pillows out from behind her body. Resident 75 stated CNA 1 did not explain what she was doing. Resident 75 stated when CNA 1 pulled the pillow out from under her neck, her head hit the mattress causing neck pain. Resident 75 stated CNA 1 then pulled the sheet off her body and threw it onto the empty bed nearby. Resident 75 stated all her pillows were also thrown onto the empty bed. Resident 75 stated she asked CNA 1 to stop, and that she did not want to continue the care because it seemed CNA 1 did not have time to change her. Resident 75 stated CNA 1 grabbed the draw sheet (a sheet placed under the resident to aid in repositioning) and pushed her over onto her side. Resident 75 stated CNA 1 had not spoken to her or explained what was going on. Resident 75 stated without verbal cueing, she had not anticipated being pushed, and her right arm hit the side rail causing pain. Resident 75 stated CNA 1's action was so forceful, she thought it would cause her to fall out of the bed. Resident 75 stated, I asked her what she was doing and she told me 'No one likes you here. You complain too much.' Resident 75 stated CNA 1 then ripped off my diaper. Resident 75 stated CNA 1 pulled the diaper off so fast and hard that it had torn in the process. Resident 75 stated CNA 1's actions had caused her pain. Resident 75 stated CNA 1 started shoving a new diaper in while she was still on her side. Resident 75 stated CNA 1 grabbed her right upper arm and pulled her on to her back without saying anything to her. Resident 75 stated CNA 1's actions caused her pain in her arm and shoulder. Resident 75 touched her right leg and stated that CNA 1 had lifted her sensitive leg up to put the diaper through and then let her leg drop onto the mattress. Resident 75 stated, She [CNA 1] hurt me. Resident 75 stated she asked CNA 1 to clean her private area as she had a urine incontinence episode. Resident 75 stated CNA 1 told her she did not need to be cleaned and did not clean her. Resident 75 stated CNA 1 began putting the pillows and sheet back on her. Resident 75 stated, I was afraid of her. Resident 75 stated no other staff had mistreated her before. Resident 75 stated it had been the first time CNA 1 was her CNA. Resident 75 stated the day after the incident (6/17/21), she did not feel well and had neck, shoulder, and arm pain. Resident 75 stated she did not have her usual appetite and her stomach was upset from the stress of it all. Resident 75 stated she had also thrown up twice because of the stress.
A review of Resident 75's Annual History and Physical dated 4/5/21, indicated the resident needed staff assistance with ambulation, bathing, continence, dressing, grooming, toileting, and transfers.
A review of Resident 75's MDS Assessment (Minimum Data Set, an assessment tool), dated 5/14/21, indicated the resident scored 13 out of 15 on the Brief Interview for Mental Status (an assessment of the resident's attention, orientation, and ability to register and recall information. A score of 13-15 was considered cognitively intact).
On 6/18/21 at 11:04 A.M., an interview was conducted with licensed nurse (LN) 5. LN 5 stated he had provided care to Resident 75 on 6/17/21. LN 5 stated Resident 75 told him she could not take her morning medications (on 6/17/21) because her stomach was upset due to having nerves from what had happened the night before (6/16/21). LN 5 stated Resident 75 told him that she had been verbally abused by the CNA the night before and had been handled very roughly. LN 5 stated Resident 75 was cognitively intact and a reliable historian. LN 5 stated the morning CNA had reported to him on 6/17/21 that Resident 75 had thrown up during her shift. LN 5 stated Resident 75 has had occasional complaints of neck pain in the past. LN 5 stated Resident 75 had complained of increased neck pain on 6/17/21 and he had called the medical doctor and received an order for an x-ray. LN 5 stated there had been no evidence of fracture or dislocation on the x-ray. LN 5 stated the only medication Resident 75 accepted from him on 6/17/21 was a pain pill. LN 5 stated it was unusual for Resident 75 to complain of nerves, nausea, and to throw up.
A review of Resident 75's electronic medication administration record (eMAR) for June 2021, indicated the resident had refused her routinely scheduled medications on 6/17/21. The June 2021 eMAR further indicated Resident 75 had requested and was administered acetaminophen (pain medication) at 12 A.M. on 6/17/21. The June 2021 eMar indicated Resident 75 had not requested nor been administered acetaminophen before 6/17/21. The June 2021 eMAR indicated Resident 75 requested and was administered Zofran (antiemetic [prevents nausea and vomiting] medication) on 6/17/21 at 3:31 A.M. The June 2021 eMar indicated Zofran had not been administered before 6/17/21. The June 2021 eMar indicated Resident 75 requested and was administered Percocet (a controlled pain medication) on 6/17/21 at 3:11 A.M. and at 7:49 A.M. The 7:49 A.M. Percocet dose was electronically signed by LN 5. The June 2021 eMar indicated the last time Resident 75 requested and was administered Percocet was on 6/11/21.
A review of Resident 75's Administration Note dated 6/17/21 at 12 A.M., indicated, Acetaminophen tablet . c/o [complains of] right shoulder pains,
A review of Resident 75's Health Status Note dated 6/17/21 at 12:44 A.M., indicated, Received resident at 2350 [11:50 P.M.]. Alert and responsive, she stated I feel nervous and she c/o pain on her right shoulder, LN noted resident able to moved [sic] her shoulder with slight facial grimacing, resident said it's just discomfort when the CNA moved me roughly. LN asked what was her pains scal [sic] and she said 4/10 [self-rated pain scale where zero is no pain and 10 the most pain]
On 6/18/21 at 11:13 A.M., an interview was conducted with CNA 3. CNA 3 stated she was familiar with Resident 75 and the resident's incontinence care routine. CNA 3 stated Resident 75 was alert and nice. CNA 3 stated Resident 75 insisted on her incontinence care being done according to her preferences. CNA 3 stated it took about 45 minutes to thoroughly perform Resident 75's incontinence care. CNA 3 stated it took a long time to provide the care according to Resident 75's preferences and that the resident would refuse to receive care if staff did not have enough time. CNA 3 stated Resident 75 would schedule time for incontinence care with CNAs once a shift. CNA 3 stated Resident 75 had a right to choose preferences for care and to have a personalized routine.
On 6/18/21 at 12:16 P.M., a telephone interview was conducted with LN 7 in the presence of the director of nursing (DON). LN 7 stated he was the LN taking care of Resident 75 on 6/16/21. LN 7 stated around 10:55 P.M. (on 6/16/21), he went to answer Resident 75's call light. LN 7 stated resident 75 seemed angry and told him CNA 1 had been rough with her causing her pain and had yanked her blankets and pillows out and threw them. LN 7 stated Resident 75 told him CNA 1 had called her a racist. LN 7 stated he had not been able to talk to CNA 1 about the incident as CNA 1 had clocked-out and was not in the facility after he spoke to Resident 75. LN 7 stated he notified the charge nurse of the incident between Resident 75 and CNA 1. LN 7 stated the charge nurse then came to assess the resident.
A review of Resident 75's Event Note date 6/16/21 at 10:55 P.M., and authored by LN 7, indicated, Resident reported that she was mistreated by the CNA that had changed her and gotten her ready for bed at 10:30 P.M., stated that the CNA roughly removed all her sheets and pillows and while changing her handled her roughly while changing her and almost making her fall off the bed when she had turned her. She also stated that she was verbally abused with CNA stating that no one liked her [Resident 75] and that she did not like black people .
On 6/18/21 at 2:28 P.M., an interview was conducted with CNA 1 in the presence of the DON. CNA 1 stated she was assigned to provide care to Resident 75 on 6/16/21. CNA 1 stated she had met with Resident 75 around 4:15 P.M. to arrange a time to do the resident's incontinence care. CNA 1 stated Resident 75 was very particular with care and the way she wanted things done. CNA 1 stated it would take a long time to complete Resident 75's incontinence care because of the specific way the resident wanted things done. CNA 1 stated they both agreed to do the care at 9:30 P.M. CNA 1 stated she fell behind schedule and went to do Resident 75's care after 10 P.M. CNA 1 stated she had asked CNA 4 to come in and help. CNA 1 stated Resident 75 seemed upset that she was late. CNA 1 stated, She [Resident 75] wasn't mad or irate though. CNA 1 stated she went and got the supplies for incontinence care and then came back into the room and started to remove Resident 75's pillows from her bed. CNA 1 denied removing any pillows that were behind Resident 75's head. CNA 1 stated she placed Resident 75's pillows, that were around the resident's arms and legs, onto the empty bed next to the resident's bed. CNA 1 gestured with her hands a gentle motion of putting the pillows down. CNA 1 stated twice that she had placed Resident 75's pillows down gently. CNA 1 denied throwing Resident 75's pillows twice. When CNA 1 was asked to clarify the issue, she made a third statement that she had tossed the resident's pillows onto the empty bed. When asked how Resident 75's incontinence brief was removed, CNA 1 stated she pulled and made a quick pulling motion with her hand while speaking, then stopped mid-sentence and stated, removed it and motioned a slow, gentle gesture of removing the straps on an incontinence brief with her hands. CNA 1 stated she did not explain the steps of the procedure with Resident 75. CNA 1 stated she did not speak with the resident because the resident had known the routine and knew that she was going to be changed. CNA 1 stated she should have explained the steps to the resident and what was happening so the resident would have a feeling of control and of being part of their own care. CNA 1 stated, I was tired. CNA 1 stated she told Resident 75 she did not have 45 minutes to change her and the resident had asked her to stop providing care. CNA 1 stated she did not stop because she was in the middle of providing care. CNA 1 stated Resident 75 had not objected to anything else while providing care. CNA 1 denied removing any blankets or sheets from the resident. CNA 1 stated Resident 75 had a sheet on, and she had folded the sheet up over the resident's chest as that was the resident's preference during care. CNA 1 stated she removed Resident 75's brief that had urine in it and put a clean brief on the resident. CNA 1 twice denied cleaning or wiping Resident 75 after removing the soiled brief. CNA 1 then made an inconsistent statement by saying that she had wiped the resident once. CNA 1 stated she had used Resident 75's draw sheet to turn the resident onto her side. CNA 1 stated three times that she had pulled Resident 75 back from a side-lying position onto her back using the draw sheet. CNA 1 denied touching Resident 75 during the process of turning the resident back. CNA 1 stated Resident 75 had held a side-lying position and did not roll back during care. CNA 1 was asked to clarify how a resident maintaining a side-lying position was pulled onto her back using the draw sheet. CNA 1 then changed her previous statements by saying she had put her hand on Resident 75's torso and gently aided the resident back onto her back. CNA 1 denied touching or using Resident 75's arm to pull the resident back onto her back. CNA 1 acknowledged there were parts of her statements that were inconsistent, but she did not provide a reason for that. CNA 1 stated three times that there had been no other dialog, conversation, or words between herself and Resident 75 after she had informed the resident that she did not have 45 minutes to change the resident. CNA 1 stated she put the pillows and sheet back over Resident 75 and was on her way out of the room carrying the soiled supplies and trash when CNA 4 entered the room to help. CNA 1 stated nothing else took place as she had been in a hurry to leave and clock-out.
A review of CNA 1's signed statement dated 6/17/21, indicated, . [Resident 75] called me into her room @ [at] 4:15 P.M. to set up a time to change her, we both agreed on 9:30 P.M. would be good. Unfortunately I was not able to keep that time due to giving care to my other PT [patient] on my last run for the night. So I reached out to my fellow coworker and asked if she could assist me around 10:15 P.M. to assist [Resident 75]. By 10:24 [P.M.] my coworker was still charting [documenting] so, I decided to go change [Resident 75] on my own like I have done before. When I got to room [number omitted] [Resident 75] was already upset because I was late. She asked why I was late and I explained and said sorry. So I proceeded to go ahead and change her. When I turned her on her side to remove wet diaper, I told her that I can't do the 45 mins [minutes] and she went off, saying 'oh no I don't want to be changed' it takes time, so she push back to lay on her back while I was removing wet diaper, I told [sic] please don't fight I'm just trying to get you dry, so I rolled her back to her side, slightly lifted up her leg to pull diaper through. She said you didn't wash me, I said you wouldn't let me. I asked her why are you being mean to me, I'm just here to help you. She say back, 'your [sic] the mean one changing me and not clean [sic] and hurting my leg. I'm reporting you . I said that's fine I didn't touch you in a bad way, you are being mean to me. By then [CNA 4] comes in and sees us and [Resident 75] says to her 'am I mean [sic] and [CNA 4] says 'No she's nice.' After that I just left the room and threw away the trash
On 6/18/21 at 3:19 P.M., a telephone interview was conducted with CNA 4 in the presence of the DON. CNA 4 stated she had provided care to Resident 75 many times and was familiar with the resident. CNA 4 stated Resident 75 was alert and oriented and would use the call light to ask staff for help when she needed care. CNA 4 stated Resident 75 would ask staff when it was a good time for them to provide care and would let staff finish what they were doing before helping her. CNA 4 stated Resident 75 had very specific preferences and was an active participant in her care. CNA 4 stated Resident 75 was known to refuse care or ask for someone else to do the care if staff rushed or did not follow her preferences. CNA 4 stated she had been working on 6/16/21 when CNA 1 had asked her to assist with Resident 75's care. CNA 4 stated CNA 1 had asked for her assistance after 10 P.M. CNA 4 stated she told CNA 1 she would be in to help after she finished documenting her assigned residents' care. CNA 4 was asked to describe what she saw when she entered Resident 75's room to help with care. CNA 4 stated, Oh, wow. CNA 4 stated CNA 1 had been completely finished and no longer needed her help. CNA 4 stated eleven minutes had passed from the time CNA 1 asked for her help until the time she entered Resident 75's room. CNA 4 stated she knew it was eleven minutes because she saw the time on the computer she was charting on. CNA 4 stated it usually took 45 minutes to complete Resident 75's care and that eleven minutes was too fast. CNA 4 stated, I wasn't expecting it to be that quick. CNA 4 stated CNA 1 was coming out of Resident 75's room carrying trash and CNA 1 stated to her, She's [Resident 75] a racist. CNA 4 stated CNA 1 made that statement in front of Resident 75 and that the resident heard the statement. CNA 4 stated after CNA 1 had left the room, Resident 75 told her, I'm not a racist. CNA 4 stated Resident 75 was distressed by CNA 1's comment. CNA 4 stated CNA 1's comment to Resident 1 was not acceptable. CNA 4 further stated that Resident 75 was strong enough to help with turning in bed and that the resident did not require staff to turn her with the draw sheet. CNA 4 stated Resident 75 was able to hold a side-lying position and would turn herself back over onto her back with verbal cueing from staff. CNA 4 stated Resident 75's care routine involved taking her sheet or blanket entirely off during the care. CNA 4 stated she was not familiar with folding the sheet over the resident's chest. CNA 4 stated Resident 75 considered a thorough cleaning of her private area after an incontinence episode as an important part her care. CNA 4 stated staff were allowed to stay overtime if it was needed in order to finish providing care to a resident.
A review of Resident 75's Psychosocial Note dated 6/17/21, indicated, MSW [medical social worker] met with the resident at bedside in regards to the resident's complaint of rough handling and verbal abuse to the DON . Resident stated 'last night the CNA came to change me and during the process the CNA was rough and hurt my neck. I already have neck issues due to my arthritis, but when the CNA removed my pillow from my head, she pulled it out hard and my head fell back. Also while moving me, I asked her to please be careful, but she kept pulling me around hard. When she removed my diaper, she pulled it from the bottom so hard that it tore.' MSW asked resident if anything else occurred, and resident stated, 'the CNA was telling me nobody likes me here and that none of the staff could stand her.' Resident informed MSW that she felt hurt and upset because of those comments
On 6/21/21 at 8:31 A.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated she managed CNAs and they reported to her. The DSD stated she was also responsible for providing staff education to include abuse prevention training. The DSD stated she was aware of Resident 75's preferences related to incontinence care. The DSD stated it was her expectation that CNAs honored Resident 75's preferences and performed the care the way the resident preferred it, no matter the time it required. The DSD stated it was her expectation that CNAs explained the care to the resident and included the resident in the care. The DSD stated it was unacceptable to not communicate with a resident. The DSD stated when a resident asked for staff to stop providing care, the staff should have immediately stopped. The DSD stated being rough with a resident could be perceived by a resident as abusive. The DSD stated providing cleaning to a resident after an incontinence episode was an expectation. The DSD stated not providing cleaning after an incontinence episode could be perceived as neglect. The DSD stated causing a resident pain by being rough during care and telling a resident that no one liked them and calling them a racist could be perceived as abuse. The DSD stated the incident that occurred on 6/16/21 between CNA 1 and Resident 75 was abusive to the resident. The DSD stated, This is abuse. The DSD stated when Resident 75 experienced being upset to her stomach and complained of having nerves after the incident on 6/17/21 that this was a psychosocial outcome. The DSD reviewed CNA 1's abuse and neglect prevention training that was done on CNA 1's orientation (5/20/21). CNA 1's Checklist for New Facility Associate Orientation with date of hire: 5/20/21, indicated, The following policies were provided to me during facility orientation: .Elder Justice Act, Resident Abuse Policy, .Respect/Harassment, Resident Rights, Associate Code of Conduct .The above information has been explained to me during facility orientation. I understand I am responsible for knowing and following the policies and procedures relating to these topics . The Checklist for New Facility Associate Orientation was signed by CNA 1 on 5/20/21. The DSD stated CNA 1 had received abuse and neglect prevention training. The DSD stated CNA 1 would have known that her conduct on 6/16/21 was wrong and went against her training.
On 6/21/21 at 1:15 P.M. a joint interview was conducted with the DON and the facility's administrator (ADM). The DON stated when Resident 75 asked CNA 1 to stop providing care, CNA 1 should have stopped. The DON stated when Resident 75 was treated roughly, told no one liked her, and was called a racist by CNA 1, that it was abuse. The ADM stated the incident that occurred on 6/16/21 between CNA 1 and Resident 75 could be perceived as abuse by the resident. The ADM stated this was an ugly situation that should never have happened. The ADM stated CNA 1 had made inconsistent statements. The ADM stated he found Resident 75 to be credible in her accounting of the events on 6/16/21, and that the facility had substantiated Resident 75's allegation of verbal abuse. The ADM stated Resident 75 may have been exhibiting anxiety on 6/17/21 related to the incident on 6/16/21 when the resident complained of nausea and vomiting. The ADM stated CNA 1's conduct had been totally unacceptable. The ADM stated the facility had zero tolerance that type of behavior.
A review of the facility's policy titled Protection of Residents: Reducing the Threat of Abuse and Neglect, reviewed 5/15/20, indicated, . Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone . Residents must not be subjected to abuse by anyone
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 75), had their right t...
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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 30 sampled residents (Resident 75), had their right to refuse care honored, when certified nursing assistant (CNA) 1 continued to provide care after Resident 75 had refused care.
This failure had the potential for Resident 75 to feel disrespected.
Findings:
Resident 75 was readmitted to the facility on [DATE], per the facility's admission Record.
On 6/18/21 at 9:06 A.M., an interview was conducted with Resident 75 inside the resident's room. Resident 75 stated she had an incident with her assigned CNA (CNA 1) the other night on 6/16/21. Resident 75 stated she had a specific way she preferred to be cleaned after an incontinence (inability to control urine and feces) episode and that her personal hygiene routine took time. Resident 75 stated she saw CNA 1 around 4 P.M. on 6/16/21, and they both agreed upon 9:30 P.M. as the time to change her incontinence brief. Resident 75 stated CNA 1 arrived to change her after 10 P.M. Resident 75 stated she had asked CNA 1 what took her so long to arrive, and CNA 1 told her that she had to care for other residents. Resident 75 stated CNA 1 seemed to have been in a bad mood. Resident 75 stated CNA 1 began to yank the pillows out from behind her body. Resident 75 stated CNA 1 did not explain what she was doing. Resident 75 stated CNA 1 then pulled the sheet off her body and threw it onto the empty bed nearby. Resident 75 stated all her pillows were also thrown onto the empty bed. Resident 75 stated she asked CNA 1 to stop, and that she did not want to continue the care because it had seemed CNA 1 did not have time to change her. Resident 75 stated CNA 1 did not stop and continued to provide care.
A review of Resident 75's MDS Assessment (Minimum Data Set, an assessment tool), dated 5/14/21, indicated the resident scored 13 out of 15 on the Brief Interview for Mental Status (an assessment of the resident's attention, orientation, and ability to register and recall information. A score of 13-15 was considered cognitively intact).
On 6/18/21 at 11:13 A.M., an interview was conducted with CNA 3. CNA 3 stated she was familiar with Resident 75 and her preferences for incontinence care. CNA 3 stated Resident 75 would insist on having incontinence care done the way she wanted. CNA 3 stated Resident 75's routine took about 45 minutes and CNAs needed to schedule that time with the resident. CNA 3 stated Resident 75 would refuse care if staff did not have the time to clean at the resident's pace or did not follow the resident's steps in cleaning.
On 6/18/21 at 2:28 P.M., an interview was conducted with CNA 1 in the presence of the director of nursing (DON). CNA 1 stated she was assigned to provide care to Resident 75 on 6/16/21. CNA 1 stated she had met with Resident 75 around 4:15 P.M. to arrange a time to do the resident's incontinence care. CNA 1 stated Resident 75 was very particular with care and the way she wanted things done. CNA 1 stated it would take a long time to complete Resident 75's incontinence care because of the specific way the resident wanted things done. CNA 1 stated they both agreed to do the care at 9:30 P.M. CNA 1 stated she fell behind schedule and went to do Resident 75's care after 10 P.M. CNA 1 stated she went and got the supplies for incontinence care and then came back into the room and started to remove Resident 75's pillows from her bed and to provide care. CNA 1 stated she told Resident 75 she did not have 45 minutes to change her and the resident had asked her to stop providing care. CNA 1 stated she did not stop because she had been in the middle of providing care.
A review of CNA 1's signed statement dated 6/17/21, indicated, . [Resident 75] called me into her room @ [at] 4:15 P.M. to set up a time to change her, we both agreed on 9:30 P.M. would be good. Unfortunately I was not able to keep that time due to giving care to my other PT [patient] on my last run for the night. So I reached out to my fellow coworker and asked if she could assist me around 10:15 P.M. to assist [Resident 75]. By 10:24 [P.M.] my coworker was still charting [documenting] so, I decided to go change [Resident 75] on my own like I have done before. When I got to room [number omitted] [Resident 75] was already upset because I was late. She asked why I was late and I explained and said sorry. So I proceeded to go ahead and change her. When I turned her on her side to remove wet diaper, I told her that I can't do the 45 mins [minutes] and she went off, saying 'oh no I don't want to be changed' it takes time, so she push back to lay on her back while I was removing wet diaper, I told [sic] please don't fight I'm just trying to get you dry, so I rolled her back to her side, slightly lifted up her leg to pull diaper through
On 6/18/21 at 3:19 P.M., a telephone interview was conducted with CNA 4. CNA 4 stated Resident 75 had specific preferences for incontinence care. CNA 4 stated Resident 75 would refuse care or ask staff to get someone else if staff did not follow her preferences. CNA 4 stated CNAs had to allot about 45 minutes to perform Resident 75's incontinence care once a shift. CNA 4 stated Resident 75 would ask staff when was a good time for them to do her incontinence care and would let staff finish what they were doing before providing care. CNA 4 stated Resident 75 had the right to refuse care. CNA 4 stated if a resident asked for care to stop then it should have stopped.
On 6/21/21 at 8:31 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated residents had the right to refuse care. The DSD stated when Resident 75 asked CNA 1 to stop providing care, CNA 1 should have stopped. The DSD stated Resident 75's right to refuse had not been honored.
On 6/21/21 at 1:15 P.M., an interview was conducted with the director of nursing (DON) and facility administrator. The DON stated Resident 75's right to refuse care had not been honored by CNA 1. The DON stated when Resident 75 asked CNA 1 to stop providing care, the CNA should have stopped.
A review of the facility's policy titled Resident Rights dated 6/8/20, indicated, .12. The resident has the right to request, refuse, and/or discontinue treatment
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 247) was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 247) was free from restraints when approximately seven to nine pillows were utilized in order to keep the resident from leaving the bed.
This deficient practice had a potential negative psychosocial impact for Resident 247's wellbeing by being restrained.
Findings:
Resident 247 was admitted to the facility on [DATE], per the facility's admission record.
A review of Resident 247's admission History and Physical dated 5/28/21, indicated the resident was diagnosed with dementia (a group of thinking and social symptoms characterized by memory loss that interferes with daily functioning).
On 6/15/21 at 12:03 P.M., an observation of Resident 247 was conducted in the resident's room. Resident 247 was in bed laying on her back, partially covered with a sheet. Resident 247 was on a low air loss mattress (specialized mattress used to prevent pressure injuries) and had two full-sized pillows under each arm that were placed against the quarter side rails (guard rails that attach to the bed frame). Resident 247 had one full-sized pillow behind her head and approximately three to four full-sized pillows under her legs. The head of the bed was raised about 30 degrees and the foot of the bed was raised about 30 degrees. No landing mats (to cushion a fall) was observed. An interview was attempted with Resident 247. Resident 247 spoke with a soft voice in a mix of English and a foreign language that was unintelligible.
A review of Resident 247's MDS Assessment (Minimum Data Set, an assessment tool) dated 6/1/21 indicated the resident was unable to complete the Brief Interview for Mental Status (determines a resident's attention, orientation, and ability to register and recall information).
On 6/15/21 at 3:21 P.M., a joint observation of Resident 247 and interview was conducted with licensed nurse (LN) 2. Resident 247 was observed in bed in the same position with the same amount of pillows and bed position as previously observed at 12:03 P.M. LN 2 stated Resident 247 was confused and the pillows had been arranged under and around the resident to buy time and slow her down from getting out of bed. LN 2 stated this had been done so staff could get to her in time to prevent a fall. LN 2 stated she had been informed in report that the resident was always getting up. LN 2 stated Resident 247 was not strong enough to go over the pillows and get out of bed. LN 2 stated Resident 247 could not remove the pillows on her own. LN 2 stated the pillows prevented Resident 247 from getting out of bed.
A review of Resident 247's Health Status Note dated 6/14/21, indicated, . Previous nurses reported resident was found walking to the bathroom by herself without assistance. Has unsteady gait
On 6/16/21 at 4:53 P.M., an observation of Resident 247 was conducted. Resident 247 was observed in bed in the same position with the same amount of pillows and bed position as previously observed on 6/15/21 at 12:03 P.M. and at 3:21 P.M.
On 6/16/21 at 5:19 P.M., a joint observation of Resident 247 and interview with certified nursing assistant (CNA) 8 was conducted. Resident 247 was observed in bed in the same position with the same amount of pillows and bed position as previously described observations. CNA 8 stated Resident 247 was mostly confused and could not walk well. CNA 8 stated she had been told Resident 247 would get out of bed a lot and would fall. CNA 8 stated Resident 247's pillows were placed under and around the resident to keep the resident in bed so she did not get up. CNA 8 stated Resident 247 could not get out of bed with all the pillows currently in place and with the side rails up. CNA 8 stated Resident 247 could not remove the pillows by herself. CNA 8 stated Resident 247 would get out of bed on her own if the pillows were not there. CNA 8 stated it was unsafe for Resident 247 to get up alone.
A review of Resident 247's medical record was conducted. The utilization of pillows to keep Resident 247 in bed was not documented as part of the resident's plan of care.
On 6/17/21 at 3:27 P.M., a joint interview and record review was conducted with LN 10. LN 10 stated using approximately nine full-sized pillows to keep a resident in bed was considered a restraint. LN 10 stated if Resident 247 could not remove the pillows herself and they prevented her from leaving the bed then they were used as a restraint. LN 10 stated if staff were concerned Resident 247 would fall then least restrictive measures should have been used first such as a landing mat. LN 10 reviewed Resident 247's clinical record and stated keeping the resident in bed was not part of the resident's plan of care.
On 6/21/21 at 8:31 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated staff should not have been using pillows to keep Resident 247 in bed as that was considered the use of a restraint. The DSD stated if there was a concern about falls then least restrictive measures should have been put into place first.
On 6/21/21 at 1:15 P.M., an interview was conducted with the director of nursing (DON). The DON stated pillows could be considered a restraint if they were used to confine a resident to the bed and the resident could not remove them by themselves. The DON stated pillows should not have been used as a restraint with Resident 247.
A review of the facility's policy titled, Restraint & Position Change Alarm Use, dated 5/12/20, indicated, .The intent is for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical restraints for discipline or convenience, prohibits the use of physical restraints to unnecessarily inhibit a resident's freedom of movement or activity,
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete baseline care plans for 3 of 21 sampled resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete baseline care plans for 3 of 21 sampled residents (Residents 71, 199 and 200). This failure had the potential for registered nurses (RN's) and licensed vocational nurses (LVN's) and certified nursing assistant (CNA's) with the inability to care for the sampled residents.
Findings:
Resident 71 was re-admitted to the facility on [DATE] with diagnoses to include generalized weakness and urinary tract infection (UTI - an infection in any part of the kidneys, bladder and or urethra).
During initial tour of the facility on 06/15/21 at 3:13 PM the resident was observed on her back in bed with eyes closed. Call light was within reach, water pitcher on the bed side table, Foley catheter (a flexible tube inserted into the bladder) covered with a dignity bag and a nasal cannula (NC- device used to deliver supplemental oxygen to a person in need of respiratory help.)
During a review of Resident 71's, care plans on 06/18/21, at 09:38 A.M. with RN 31. RN 31 stated, when a resident comes in with a Foley catheter there should be a care plan implemented by the admitting RN. RN 31 also stated there was no evidence of a Foley catheter care plan for Resident 71.
The readmission Collection Tool, dated 6/5/2021, was reviewed, with RN 31, section 9. Genitourinary has the urinary catheter circle highlighted in black.
During a review of the facility's undated policy and procedure (P & P) titled, Resident Assessment Instrument & Care Plan, indicated, The Care Plan includes measure objectives, timeframes to meet the patient's, cultural, nursing, mental, and psychosocial needs including services being provided to meet those needs.
During an interview with Director of Nursing (DON) on 06/18/21 at 10:08 AM the care plans for Resident 71 were reviewed. The DON stated there is no evidence of a care plan for a Foley catheter. The DON further stated she would expect care plan on admission back to the unit or within 48 hours. Care plans are important because it helps educate staff on how to take care of various issues with the residents, including how and what to expect when taking care of a resident with a Foley catheter.
Resident 199 was admitted to the facility on [DATE] with diagnoses to include cellulitis (bacterial skin infection.)
During the initial tour of the facility 06/15/21 at 3:30 P.M., Resident 199, was observed in bed, with a peripheral inserted catheter (PIV.) in her right hand. At the bedside was an IV pole with IV antibiotics hanging on the IV pole.
During a subsequent interview on 6/15/2021 at 3:46 P.M., with RN 32. RN 32 acknowledged that, there is no date or RN signature of who started the PIV or the size of the needle. RN 33 further stated there was no label on the tubing letting other RN's know when the IV tubing was hung or when to replace the tubing.
During an interview and record review with RN 33, on 06/17/21, at 3:54 P.M., RN 33, stated we change peripheral IV sites every 72 hours and put on the occlusive dressing (air and water tight trauma medical dressing used in first aid) our initials, date and needle size on the dressing then we put in a care plan. RN 33, acknowledged that there is no care plan for the PIV site or a care plan for the IV antibiotics that are infusing for the resident.
During a subsequent review of the physicians order dated 6/4/2021, the physicians order stated, unasyn 3g IV q 6h for cellulitis.
During a review of the facility's undated policy and procedure (P & P) titled, Resident Assessment Instrument & Care Plan, indicated, The Care Plan includes measure objectives, timeframes to meet the patient's, cultural, nursing, mental, and psychosocial needs including services being provided to meet those needs.
During an interview with Director of Nursing (DON) on 06/18/21 at 10:08 AM the care plans for Resident 199 was reviewed. The DON stated there is no evidence of a care plan for the PIV site or the antibiotics for Resident 199. The DON further stated she would expect care plan when the PIV site was inserted or within 48 hours. Care plans are important because it helps educate staff on how to take care of various issues with the residents.
Resident 200 was admitted to the facility on [DATE]with diagnoses to include type 2 diabetes (DM - chronic condition that affects the way the body processes blood sugar).
During the initial tour of the facility 06/15/21 at 4 P.M., Resident 200 was observed sitting in a wheelchair watching TV. There was an IV pole behind Resident 200, with an IV bag hanging unattached from the IV machine. The 100 ml of NS bag had Cefezolin 1 gm written in black sharpie on the side of the bag.
During a subsequent interview with RN 31, she stated this in not correct, there should be a name of the patient on the bag, the name of the nurse and when hung and a label on the IV tubing that states when the IV tubing was put up and when the IV tubing should be changed.
During a concurrent interview and record review, on 06/17/21, at 4:20 PM, with RN 33. RN33 stated that there is no evidence of a care plan for Resident 200 for DM, antibiotics or the PIV. RN 33 further stated, we are supposed to update the care plan, if one is not started then we initiate. There is a separate care plan for PIV and another one for IV antibiotics.
During a review of the facility's undated policy and procedure (P & P) titled, Resident Assessment Instrument & Care Plan, indicated, The Care Plan includes measure objectives, timeframes to meet the patient's, cultural, nursing, mental, and psychosocial needs including services being provided to meet those needs.
On 6/18/21 10:15 A.M., with DON. The DON stated I would expect the care plan for the DM, antibiotics, and the PIV, to be implemented within 48 hours. Care plans are important because it helps educate staff on how to take care of various issues with the 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** 3. Resident 32 was readmitted to the facility on [DATE] with diagnoses that included traumatic brain injury (sudden injury that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 32 was readmitted to the facility on [DATE] with diagnoses that included traumatic brain injury (sudden injury that causes damage to the brain), functional quadriplegia (paralysis of all four limbs) and dysphagia (a difficulty in swallowing), per the facility's admission Record.
On 6/16/21 at 10 A.M., a concurrent observation and interview of Resident 32 was conducted with licensed nurse (LN) 10. Resident 32 was observed with a white surgical facemask inside his mouth. LN 10 stated Resident 32 had a tendency of putting anything that was placed above his chest into his mouth. LN 10 stated staff were not allowed to put a facemask on Resident 32 because he would put it in his mouth.
A review of resident 32's care plan was conducted. A care plan was developed on 6/16/21, after Resident 32 was observed with a facemask inside his mouth. There was no written care plan developed, related to Resident 32's behavior of putting things in his mouth, prior to 6/16/21.
On 6/21/21 at 4:10 P.M., an interview the director of nursing (DON) was conducted. The DON stated a care plan that addressed Resident 32's choking risk should have been developed because it was a means a of communication among healthcare staff.
A review of the facility's policy titled Resident Assessment Instrument & Care Plan dated 6/8/20, indicated, . The RAI [resident assessment instrument] is not all inclusive therefore other sources of information are to be included when developing an individualized person-centered care plan for each patient . The care plan includes measure [sic] objectives, timeframes to meet the patient's cultural, nursing, mental, and psychosocial needs including services being provided to meet those needs
2. Resident 50 was readmitted to the facility on [DATE] with diagnoses that include deficiency (lack of) of B group vitamins, aphasia (loss of ability to express speech caused by brain damage), and cerebral infarction (lack of blood supply to the brain causing brain damage) affecting the left dominant side (left side of body) per the facility's admission Record.
On 06/15/21 at 11:01 A.M., an observation and interview were conducted with Resident 50. Resident 50 appeared to have no top teeth when observed during interview. Resident 50 stated she had no dentures but would like some very much. Resident 50 stated she had no top teeth and only a few bottom teeth. Resident 50 smiled and said, that would be great if I could get dentures.
On 06/17/21 a review of Resident 50's medical record (MR) and electronic medical record (EMR) was conducted. There is no documented evidence that the facility obtained informed consent or coordinated an appointment for Resident 50 to get dentures per the dental order that was written 9/10/2019. The EMR in section, Progress Notes, dated 9/10/2019 indicated, Progress note received from dental office, TAR (Treatment Authorization Request) pending for upper dentures. The EMR indicated Resident 50 was on a regular diet with thin liquids per the medical doctor's order. The EMR indicated in the Minimum Data Set Assessment (MDS -assessment tool), section L, that resident had her own teeth on admission date 2/23/18 and in the last quarterly assessment 4/30/21 the resident had cracked and broken natural teeth. The EMR or MR did not indicate that the resident was admitted with dentures. The EMR did not indicate in the resident's care plan anything related to the resident not having teeth.
On 06/18/21 at 3:06 P.M., an interview was conducted with Resident 50. Resident 50 stated she had dentures when she first came to the facility, but they lost them.
On 06/21/21 at 10:59 A.M., an interview and concurrent record review were conducted with the facility's Director of Staff Development (DSD) and Director of Social Services (DSS). The DSD stated there is no careplan related to dental or dentures in Resident 50's medical record. The DSS and the DSD stated all residents admitted to the facility that do not have teeth should have an initial and ongoing careplan addressing the needs of the resident. The DSD stated she could not locate in Resident 50's medical record an initial or ongoing careplan related to resident not having teeth. The DSD stated she could not locate any documentation in Resident 50's medical record where the facility's registered dietitian noted that the resident did not have any teeth.
Based on observation, interview, and record review, the facility failed to ensure individualized and resident-specific written care plans were developed for three of 30 sampled residents (Residents 32, 50, and 75), reviewed for care planning, when:
1. Resident 75's personal preferences for incontinence (the inability to control urine or feces) care were not developed in a written care plan.
2. Resident 50's lack of teeth was not included in the development of a written care plan.
3. Resident 32's risk for choking was not developed in a written care plan.
These failures had the potential to negatively effect the residents' health, safety, quality of life, and cause miscommunication among caregivers.
Findings:
1. Resident 75 was readmitted to the facility on [DATE] with diagnoses to include urge incontinence, per the facility's admission Record.
On 6/18/21 at 9:06 A.M., an interview was conducted with Resident 75. Resident 75 stated she liked to be cleaned in a specific way after an incontinence episode. Resident 75 stated staff often wanted to clean her their way, but she would insist that they clean her according to her preferences. Resident 75 stated she had a specific order of cleaning steps and wanted staff to take their time when cleaning her up. Resident 75 stated she would schedule a mutually agreed upon time with certified nursing assistants (CNAs) so they could accommodate her routine and preferences. Resident 75 stated she preferred this routine to occur once per CNA shift.
On 6/18/21 at 11:13 A.M., an interview was conducted with CNA 3. CNA 3 stated she was familiar with Resident 75 and her preferences for incontinence care. CNA 3 stated Resident 75 would insist on having incontinence care done the way she wanted. CNA 3 stated Resident 75's routine took about 45 minutes and CNAs needed to schedule that time with the resident. CNA 3 stated Resident 75 wanted to be very clean after an incontinence episode, and would even wipe herself after the CNA was finished to make sure she was clean. CNA 3 stated Resident 75 would refuse care if staff did not have the time to clean at the resident's pace or did not follow the resident's steps in cleaning.
On 6/18/21 at 2:28 P.M., an interview was conducted with CNA 1. CNA 1 stated Resident 75 was very particular with care. CNA 1 stated it took a long time to provide incontinence care because Resident 75 had a routine for how she wanted care provided.
On 6/18/21 at 3:19 P.M., a telephone interview was conducted with CNA 4 in the presence of the director of nursing (DON). CNA 4 stated Resident 75 had very specific preferences for incontinence care. CNA 4 stated Resident 75 would refuse care or ask staff to get someone else if staff did not follow her preferences. CNA 4 stated CNAs had to allot about 45 minutes to perform Resident 75's incontinence care once a shift. CNA 4 stated Resident 75 would ask staff when was a good time for them to do her incontinence care and would let staff finish what they were doing before providing care. CNA 4 stated Resident 75 was specific about how to remove her pillows, requested towels placed a certain way during the incontinence care to prevent urine leaks, and wanted a thorough cleaning. CNA 4 stated residents' preferences during care had to be honored.
On 6/21/21 at 8:31 A.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated she was aware Resident 75 had an individualized incontinence care routine that took about 45 minutes for CNAs to complete. The DSD stated Resident 75 liked to schedule the care once a shift toward the end of the shift. The DSD stated Resident 75's preferences for incontinence care were reasonable and it was her expectation that care be provided according to the resident's preferences. The DSD reviewed Resident 75's medical record and stated the resident's preferences for incontinence care had not been a part of the resident's written plan of care. The DSD stated the written care plan was a means of communicating and directing a resident's care. The DSD stated Resident 75's incontinence care routine should have been developed in the resident's written plan of care.
On 6/21/21 at 1:15 P.M. an interview was conducted with the DON and facility administrator. The DON stated Resident 75's preferences for incontinence care should have been developed as part of the resident's written care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure wound treatment was provided in accordance wit...
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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 wound treatment was provided in accordance with the physician's order for one of 30 sampled residents (Resident 17).
This failure had a potential for Resident 17's wound to develop infection.
Findings:
Resident 17 was readmitted to the facility on [DATE], per the facility's admission Record.
During an observation on 6/16/21 at 9:23 A.M., Resident 17 had a wound dressing on his right hand with a date of 6/8 written on the dressing.
A record review was conducted. The physician's order dated 6/7/21, indicated, Right hand abrasion: cleanse with NS (Normal saline), pat dry, apply dry dressing, every day shift every 3 days.
Resident 17's June 2021 eTAR (electronic Treatment Administration Record - a record where nurses mark treatment was done) was reviewed. The June 2021 eTAR indicated the resident's wound treatment for his right hand abrasion had been initialed as done on 6/8/21, not initialed on 6/11/21, and was initialed on 6/14/21 as done by LN 10.
On 6/18/21 at 11:11 A.M., an interview with LN 10 was conducted. LN 10 stated on 6/14/21, she marked the eTAR with her initials without changing Resident 17's right hand dressing. LN 10 stated changing Resident 17's dressing according to the physician's order was important in order to assess the wound and prevent wound infection.
On 6/21/21 at 9:35 A.M., an interview with LN 5 was conducted. LN 5 stated the importance of changing Resident 17's right hand dressing was to observe the wound, prevent infection and to promote healing.
On 6/21/21 at 1:36 P.M., an interview and record review was conducted with the director of staff development (DSD). The DSD reviewed Resident 17's June 2021 eTAR and acknowledged that the treatment for the resident's right hand abrasion had not been done on 6/11/21. The DSD stated the importance of changing the dressing according to the physician's order was to assess the wound and to address any intervention if needed.
On 6/21/21 at 4:18 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated LN 10 should have conducted Resident 17's treatment as ordered by the physician.
A review of the California Nursing Practice Act, division 2, chapter 6, article 2, section 2725 indicated, (b) The practice of nursing within meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following: . (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist, as defined by section 1316.5 of the Health and Safety Code.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pressure ulcer (skin injuries caused by prolon...
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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 pressure ulcer (skin injuries caused by prolonged pressure on the skin) preventative measure was implemented when a pressure relieving mattress was not programmed in accordance with the physician's order for one of 5 residents (Resident 32) reviewed for pressure ulcer/injury.
This failure had the potential for Resident 32 to develop pressure ulcer.
Findings:
Resident 32 was readmitted to the facility on [DATE] with diagnoses that include of Traumatic brain injury (sudden injury that causes damage to the brain), functional quadriplegia (paralysis of all four limbs) per the admission Record.
On 6/16/21 at 9 A.M., Resident 32 was observed sitting on a wheelchair. Resident 32 had a pressure relieving mattress on his bed. Resident 32's mattress control panel indicated a setting of 1 was to be use for residents weighing up to 120 lbs. (pounds). The control panel also indicated, settings of 2 -5 were to be use for residents weighing more than 120 lbs. (up to 400 lbs.). Resident 32's mattress was set at 5.
A review of Resident 32's weight, dated 5/30/21, indicated a weight of 176 lbs.
A review of Resident 32's physician's order, dated 1/25/20, indicated an order for low air loss (LAL) mattress. The order indicated for license nurses (LNs) to monitor the low air loss mattress for proper placement, functionality and settings every shift. The order also indicated that the LAL mattress should be set in accordance to the resident's weight or comfort level.
A review of the Resident 32's Braden scale (scale use for predicting pressure sore risk and risk factors: 15-18 mild risk, 13-14 moderate risk, 10-12 high risk, 9 or below severe risk), dated 4/30/2021, indicated a score of 12, which meant Resident 32 was high risk for developing pressure ulcer.
A review of Resident 32's care plan, dated 4/9/21, included pressure reducing mattress as an intervention to maintain intact skin and to prevent skin breakdown.
On 6/21/21 at 9:14 A.M., an interview and joint observation were conducted with LN 10. Resident 32 was laying on his bed. Resident 32's pressure relieving mattress was set at 5. LN 10 was changed the mattress setting to 3. LN 10 stated Resident 32's mattress should be set at 3, because the resident's weight was 176 lbs.
A review of the Pressure Guard Protocol owner's manual, page 11, indicated, a setting of 1 was to be use for residents weighing up to 120 lbs. (pounds). The owner's manual also indicated, settings of 2 -5 were to be use for residents weighing more than 120 lbs. (up to 400 lbs.).
On 6/21/21 at 12:51 P.M., an interview with the Director of Staff Development (DSD) was conducted. The DSD stated Resident 32's mattress should have been set according to his weight. The DSD stated setting the mattress pressure higher than the recommendation, made the mattress harder, which could cause the resident to develop pressure ulcer.
On 6/21/21 at 4:10 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the nurses should have checked Resident 32's mattress settings daily to ensure that the settings were set according to the physician's order. The DON stated failure to follow the recommended settings could cause Resident 32 to develop pressure ulcer.
A review of the facility's policy titled Skin Integrity and Pressure Ulcer/Injury Prevention and Management, reviewed 10/14/2020, indicated, .5. Measures to protect the patient against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: . g) a pressure redistribution mattress surface is placed under the patient .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide range of motion (ROM) exercises for one of fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide range of motion (ROM) exercises for one of four residents (Resident 25) reviewed for position/mobility.
This failure had a potential for Resident 25 to develop muscle weakness and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).
Findings:
Resident 25 was readmitted to the facility on [DATE] with diagnoses that included quadriplegia (paralysis of all four limbs) per the facility's admission Record.
On 6/15/21 at 3:48 P.M., an observation and interview with Resident 25 was conducted. Resident 25's left hand and fingers was observed to be stiff. Resident 25 was able to slowly move the left hand and fingers on her own. Resident 25 stated, she was not receiving any exercises on her upper extremities. Resident 25 stated, restorative nursing assistant (RNA) 1 assisted her with sit to stand exercises. Resident 25 stated, she asked RNA 1 if she could get exercises to her upper extremities. Resident 25 stated she used a bell that she could tap, to call staff when she needed assistance, because she was having a hard time using the call light due to the weakness on both her arms and hands.
A record review of Resident 25's Minimum Data Set (assessment tool), dated 3/30/21, indicated Resident 25 had impairment on one side of her body.
On 6/17/21 at 4:05 P.M., an interview with RNA 1 was conducted. RNA 1 stated Resident 25 was not in the RNA program for years. RNA 1 stated Resident 25 requested for ROM exercises. RNA 1 stated he was not sure why Resident 25 was not in the program. RNA 1 stated, Resident 25 requested to be included in the RNA program about 2 years ago, but nothing happened.
On 6/18/21 at 2:26 P.M., an interview with the Director of Rehabilitation (DOR) was conducted. The DOR stated the Rehabilitation Department (HD) had a Restorative Nursing Program. The DOR stated the HD met with the nursing department weekly. The DOR stated the HD had oversight of the RNA program. The DOR stated, the HD screened the residents for possible enrollment into the RNA program, if appropriate. The DOR stated all residents were screened quarterly for functionality, mobility and change of condition. The DOR stated Resident 25 was screened today for ROM and was included in the RNA program. The DOR stated it was important for Resident 25 to receive ROM exercises to help maintain the resident's current functionality and strength, as well as, to prevent muscle weakness and contractures.
On 6/21/21 at 1:39 P.M., an interview with the Director of Staff Development (DSD) was conducted. The DSD stated Resident 25 should have been provided ROM exercises to prevent contractures from developing.
On 6/21/21 at 4:25 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated, residents should be screened if they need ROM exercises. The DON stated Resident 25 should have received ROM exercises to prevent contractures and muscle weakness.
A review of the facility's policy titled Range of Motion Exercises, dated 5/14/2021 was conducted. The policy did not provide guidance on how to identify residents who may need to be referred to the rehabilitation department.
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** 2. Resident 32 was readmitted to the facility on [DATE] with diagnoses that include of Traumatic brain injury (sudden injury tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 32 was readmitted to the facility on [DATE] with diagnoses that include of Traumatic brain injury (sudden injury that causes damage to the brain), functional quadriplegia (paralysis of all four limbs) and dysphagia (a difficulty in swallowing - it takes more effort than normal to move food from the mouth to the stomach) per the facility's admission Record.
On 6/16/21 at 10 A.M., Resident 32 was observed with a white surgical facemask inside his mouth. This writer called the attention of license nurse (LN) 10 to inform her about the surgical mask inside Resident 32's mouth.
On 6/16/21 at 10 A.M., an interview with LN 10 was conducted. LN 10 stated, Resident 32 had a tendency of putting anything that was placed above his chest into his mouth. LN 10 stated staff were not allowed to put a facemask on Resident 32 because he will put it in his mouth. LN 10 stated, certified nursing assistant (CNA) 16 was the person who put the face mask on Resident 32.
On 6/16/21 at 10:27 A.M., an interview with CNA 16 was conducted. CNA 16 denied putting the facemask on Resident 32, but stated that she was the CNA assigned to Resident 32.
On 6/17/21 at 12:12 P.M., an interview with CNA 8 was conducted. CNA 8 stated, Resident 32 tended to put every object that was placed above his chest into his mouth.
A review of resident 32's care plan was conducted. A care plan was developed on 6/16/21, which was the day Resident 32 was observed with a facemask inside his mouth. There was no written care plan developed, related to Resident 32's behavior of putting things in his mouth, prior to 6/16/21.
On 6/21/21 at 12:51 P.M., an interview with the Director of Staff Development (DSD) was conducted. The DSD stated, the staff were aware that Resident 32 had a tendency of putting any object placed on his chest into his mouth. The DSD stated, the facemask should not have been placed on Resident 32 because of the possibility of choking.
A review of the facility's policy titled Event Management System Policy, dated 5/15/20, purpose, was conducted. The Event Management System Policy indicated, provide an environment that is free from accident hazards, over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes:
-
Identifying hazard(s) and risk(s);
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Evaluating and analyzing hazard(s) and risk(s);
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Implementing interventions to reduce hazard(s) and risk(s); and
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Monitoring for effectiveness and modifying interventions when necessary.
Based on observation, interview, and record review, the facility failed to ensure two of 30 sampled residents (Resident 37 and 32 ) reviewed for accidents, were free from the risk of accidents and hazards when:
1. Certified nursing assistant (CNA) 1 and CNA 7 unsafely transferred Resident 37 from the resident's bed to the wheelchair.
2. Resident 32 had a crumpled up surgical mask inside of his mouth.
These failures had the potential for Resident 37 to sustain falls or other injuries, and for Resident 32 to choke.
Findings:
1. Resident 37 was admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms characterized by memory loss that interferes with daily functioning), difficulty in walking, muscle weakness, and a history of falling, per the facility's admission Record.
A review of Resident 37's Annual History and Physical dated 8/26/20, indicated, .Orientation to time, place, and person: Patient appears somewhat disoriented . Recent memory appears to be mildly impaired. Remote memory appears to be mildly impaired
A review of Resident 37's MDS Assessment (Minimum Data Set, an assessment tool) dated 4/16/21, indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) to transfer between surfaces such as the bed to wheelchair.
On 6/15/21 at 3:55 P.M., an observation was conducted with Resident 37 in the resident's room. Resident 37 was observed laying on her bed, rubbing her left upper arm and stating, dolor [pain in Spanish].
On 6/15/21 at 3:57 P.M., an interview was conducted with Resident 37 using licensed nurse (LN) 10 as an interpreter because the resident's primary language was Spanish. Resident 37 stated her left arm and shoulder hurt. Resident 37 stated her pain was caused after staff transferred her to her wheelchair. Resident 37 was unable to state when the incident occurred or with whom it had occurred. LN 10 stated Resident 37 required extensive assistance from staff and transferred from bed to wheelchair using a gait belt. LN 10 further stated Resident 37 had been assessed by the nurse practitioner on 6/15/21 for her arm and shoulder pain and that an x-ray had been ordered.
A review of the facility training document titled Lippincott procedures-Gait belt use, revised 5/21/21, .A gait belt is a safety device made of cloth or plastic that buckles securely around a patient's waist. The device provides a secure grasping surface to aid with patient transfer and ambulation. A gait belt is commonly used for patients who are at risk of falling
On 6/15/21 at 4:05 P.M., an interview was conducted with CNA 1. CNA 1 stated she was taking care of Resident 37. CNA 1 stated Resident 37 was alert, but often was confused. CNA 1 stated Resident 1 required extensive assistance during transfers. CNA 1 stated that she usually transferred the resident by hugging the resident, then moving the resident by putting her arms under the resident's armpits. CNA 1 stated Resident 37's participation during transfers was minimal and that staff performed more than 50% of the actual lift when transferring Resident 37. CNA 1 stated Resident 37 was able to pivot during transfers.
On 6/15/21 at 4:16 P.M., an observation was conducted while CNA 1 and CNA 7 transferred Resident 37. Resident 37 was laying on her side facing both CNAs. CNA 1 moved Resident 37's legs off the bed and then lifted the resident's upper body up so the resident was in a sitting position toward the edge of the bed. CNA 7 was observing CNA 1. CNA 1 raised up Resident 37's bed. Resident 37's feet were approximately 3 inches off the floor. Resident 37 was not assisted closer to the edge of the bed. CNA 1 took hold of Resident 37's right upper arm and pulled the resident up, approximately two feet off the mattress, to a semi-standing position. CNA 1 placed her arm underneath Resident 37's right armpit and CNA 7 put her arm under Resident 37's left armpit, and the resident was lifted to a fully standing position. Resident 37 was not an active participant in the maneuver. Resident 37 had been observed with facial grimacing during the maneuver. Resident 37 was standing at the side of her bed and a wheelchair was approximately two feet away from the resident. CNA 1 took hold of the right side of Resident 37's pants and CNA 7 took hold of the left side of the resident's pants. CNA 1 and CNA 7 manually twisted Resident 37 by the pants so that the resident's buttocks were in front of the wheelchair. Resident 37's legs and knees twisted with the maneuver, but the resident's feet remained mostly stationary. CNA 1 stated, See she can pivot. CNA 1 placed Resident 37 into her wheelchair and the resident was brought into the resident's bathroom. CNA 1 and CNA 7 had not used a gait belt while transferring Resident 37. The steps of the process had not been explained to the resident. Verbal cues were not provided to Resident 37 during the transfer.
On 6/17/21 at 11:21 A.M., a joint interview and record review was conducted with LN 11. LN 11 stated Resident 37 was often confused and she did not consistently understand the resident even though she also spoke Spanish. LN 11 stated Resident 37 had recently complained of arm and shoulder pain and told her that staff had lifted her by her arm when putting her in her wheelchair. LN 11 reviewed Resident 37's medical record and stated an x-ray was done on 6/15/21 for the resident's shoulder and there was no fracture or dislocation. LN 11 stated it was her expectation for staff to use a gait belt in order to safely transfer Resident 37. LN 11 stated using a resident's arm to lift as part of the transfer technique was not an appropriate technique and was unsafe. LN 11 stated pivoting a resident by their pants was not an acceptable practice and could result in injury.
On 6/17/21 at 11:45 A.M., an interview was conducted with restorative nursing assistant (RNA) 1. RNA 1 stated all residents requiring assistance with transfers had to be transferred with a gait belt for safety. RNA 1 stated if staff forgot to bring a gait belt into the room, they should stop what they were doing and go get one. RNA 1 stated transferring a resident who required extensive assistance by lifting up on an arm, lifting under armpits, and turning the resident by the pants, were not acceptable transfer methods. RNA 1 stated all staff received training on proper transfer techniques and for the use of the gait belt. RNA 1 stated both residents and staff could get hurt or injured when staff did not follow their training.
On 6/17/21 at 11:57 A.M., an interview was conducted with physical therapy assistant (PTA). PTA stated residents who required extensive assistance should be brought to a sitting position in bed in one fluid movement of legs and upper body together. PTA stated the gait belt should be used on all residents during transfers for safety. PTA stated during transfers, staff should pass their arm through the resident's arm to grab onto the gait belt and lift by the gait belt when assisting the resident to a standing position. PTA stated a resident's underarm should not receive the pressure of the lift. PTA stated residents had to be scooted to the edge of the bed until their feet touched the floor prior to attempting to stand the resident. PTA stated a resident requiring extensive assistance should not have been lifted by one arm to almost standing as that could have caused injury to the resident.
On 6/17/21 at 2:55 P.M., an interview was conducted with the director of staff development (DSD). The DSD stated she managed the CNAs and they reported to her. The DSD stated she was responsible for training and assessing CNA competencies. The DSD stated all staff received training on proper transfer techniques and were deemed competent after a written test was passed and a return demonstration was successful. The DSD stated the transfer training occurred upon hire and during periodic in-services. The DSD stated lifting a resident who required extensive assistance by one arm was not an acceptable practice and could injure the resident. The DSD stated pressure applied under a resident's armpits could also lead to injuries. The DSD stated a resident should not be pivoted by their pants. The DSD stated Resident 37 should have been transferred with a gait belt to prevent potential injuries and falls. The DSD stated CNA 1 had received proper transfer technique training. The DSD stated she recalled CNA 1 correctly performing the return demonstration. The DSD stated CNA 1 knew the correct method for transferring a resident requiring extensive assistance. The DSD stated CNA 1 and CNA 7 did not transfer Resident 37 safely and in accordance to their training.
On 6/17/21 at 4:24 P.M., the DSD provided copies of CNA 1's training documents. The document titled Body Mechanics/Transfer Training Demonstration Checklist was dated 5/20/21 and was signed by the DSD and CNA 1. The document indicated CNA 1 had successfully demonstrated: Assisting a resident from supine to sitting on edge of bed, one person transfer from bed to wheelchair with gait belt, and two person transfer from bed to wheelchair with gait belt.
On 6/18/21 at 9:48 A.M., an interview was conducted with the director of nursing (DON). The DON stated the facility did not have a policy related to transferring residents. The DON provided the video titled [NAME] Video Series for Nursing Assistants and stated it was used as part of the transfer training. The DON provided a copy of the training lesson plan titled Lippincott procedures-Gait belt use, revised 5/21/21, and stated this was the content taught to the staff. The DON stated all staff were expected to follow the training when transferring residents. The DON stated CNA 1 taking hold of Resident 37's right upper arm and pulling the resident up to a semi-standing position was not acceptable. The DON stated Resident 37 had not been transferred according to her expectations. The DON stated the way Resident 37 was transferred on 6/15/21 by CNA 1 and CNA 7 could have resulted in pain and injury to the resident.
On 6/18/21 at 2:28 PM an interview was conducted with CNA 1 in the presence of the DON. CNA 1 stated she had received training on how to safely transfer residents and on the proper use of the gait belt. CNA 1 acknowledged her transfer of Resident 37 on 6/15/21. CNA 1 stated, My boo-boo [mistake] was not having gait belt. I should have had a gait belt. CNA 1 stated gait belts were supposed to be used in order to safely transfer residents. CNA 1 was asked to discuss the steps she utilized in transferring Resident 37 on 6/15/21. CNA 1 stated, I do not recall how I transferred her.
On 6/21/21 at 12:40 P.M., an interview was conducted with CNA 7 with a staff interpreter and in the presence of the DON. CNA 7 acknowledged she was present on 6/15/21 and had assisted CNA 1 to transfer Resident 37 from the resident's bed to the wheelchair. CNA 7 stated she had waited for CNA 1 to tell her what to do and how to help with the transfer. CNA 7 stated she was trained how to safely transfer residents. CNA 7 stated the transfer of Resident 37 had not been done normally. CNA 7 stated Resident 37 had not been transferred according to the training she had received. CNA 7 stated Resident 37 had not been transferred with a gait belt, and should have been. CNA 7 stated Resident 37's feet were not fully on the floor when the transfer began, and should have been. CNA 7 stated she did not observe CNA 1 lift Resident 37 up off the bed by the right arm as, I was concentrating on my part. CNA 7 stated she felt comfortable enough to speak up if she saw an unsafe practice such as not using a gait belt. CNA 7 stated she did not say anything at the time of the transfer because she wasn't thinking.
A review of the facility training document titled Lippincott procedures-Gait belt use, revised 5/21/21, indicated, .Transferring the patient .Position yourself close to the patient so that you're facing each other. Grasp both sides of the gait belt using an underhand grip . Instruct the patient, on a count of three, to push off the bed . Pivot on your back foot and avoid twisting
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label the peripherally inserted venous catheter (PIV/...
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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 label the peripherally inserted venous catheter (PIV/IV - needle inserted into a blood vessel used for hydration and/or medication) site with date, time, and initials of the licensed nurse (LN) for one of 30 sampled residents (Resident 199).
This failure had the potential to increase Resident 199's risk of infection.
Findings:
Resident 199 was admitted to the facility on [DATE], with diagnoses that included cellulitis (bacterial skin infection), per the facility's admission Record.
During the initial tour of the facility on 6/15/21 at 3:30 P.M., Resident 199, was observed in bed, with a PIV in her right hand. At the bedside, was an IV antibiotic hanging on the IV pole. The PIV site on Resident 199's right hand did not indicate the date, time, initials, and size of the needle used.
During a subsequent interview with LN 32 on 6/15/21 at 3:46 P.M., LN 32 stated there was no time or date it was inserted, initials, or size of the needle used. LN 32 further stated there was no label on the tubing to inform other LNs when the IV tubing was inserted or when to replace the tubing.
During an interview and record review with LN 33 on 06/17/21 at 3:54 P.M., LN 33, stated We change peripheral IV sites every 72 hours and put on the occlusive dressing (air and water tight dressing) our initials, date and needle size on the dressing.
During an interview with Director of Nursing (DON) on 06/18/21 at 10:08 A.M., the DON stated the PIV site should have been dated, timed, with the gauge size of the needle inserted, placed on the occlusive dressing. The DON further stated without this information the facility would not know when the PIV was inserted or when to change the IV tubing.
During a review of the facility's policy and procedure titled Insertion of a Peripheral IV (Over the Needle, Peripheral Short) Catheter, revised December 2011, indicated, Purpose: The purpose of this procedure is to provide guidelines for the safe and aseptic insertion of a peripheral .intravenous catheter for the administration of intravenous fluids and or medications . Dressings .Label on dressing should include date and time of dressing placement, initials, gauge size, and length of catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
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 consistent completion of hemodialysis (dialysi...
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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 consistent completion of hemodialysis (dialysis- a life support treatment that replaces many of the kidney's functions) assessments for 2 of 2 sampled dialysis residents (Resident 21 and 36).
This failure had the potential for miscommunication between the facility and dialysis center and to affect the continuity and quality of care for Resident 21 and Resident 36.
Findings:
1. Resident 21 was admitted to the facility on [DATE] with diagnoses, which included end stage renal disease (kidney failure), per the facility's admission Record.
During an interview with Resident 21 on 6/16/21 at 9:15 A.M., the resident stated he went out for dialysis three times a week every Tuesday, Thursday, and Saturday.
During an interview with the assistant director of nursing (ADON) on 6/18/21 at 9:59 A.M., the ADON stated each dialysis resident had a binder that went with them to each treatment at the dialysis center. The ADON stated the Pre/Post Dialysis Communication sheet was the primary form of communication between the facility and the dialysis center. The ADON stated this sheet included the facility's assessment pre/post-treatment and provided important information regarding the resident care during the dialysis treatment. The ADON stated if the dialysis center did not complete the communication sheet, the licensed nurse (LN) was to fax the sheet to the dialysis center, then call and request the form to be completed and returned to the facility.
During a concurrent interview and record review on 6/18/21 at 10:02 A.M., Resident 21's Dialysis Communication sheets, dated 5/27 to 6/15/21, were reviewed. The ADON stated communication from the dialysis center was completely blank for 6/8, 6/10, and 6/12/21, with no indication of weights, vital signs, assessment of the access site, or any other information during the treatment. The ADON stated the dialysis center should have completed the communication sheets because details of what occurred when the resident was at dialysis were important to ensure any needed follow-up care was provided.
During the same interview and record review, The ADON stated the resident's post-assessment was completely blank for 6/1/21, with no indication of weight, vital signs, or assessment of Resident 21's access site. The ADON stated the post-assessment was important to ensure the resident was stable after their dialysis treatment.
2. Resident 36 was admitted to the facility 4/7/20 with diagnoses including end-stage renal disease (kidney failure) and dependence on dialysis, per the facility's admission Record.
On 6/18/21 at 9:40 A.M., Resident 36 was observed sitting in a wheelchair by the elevator. The resident stated he was waiting for the elevator but could not say where he was going due to his cognitive status.
During an interview with the ADON on 6/18/21 at 9:59 A.M., the ADON stated Resident 36 was by the elevator waiting to be transported to dialysis. The ADON stated the resident went for dialysis three times a week, every Monday, Wednesday, and Friday.
During a concurrent interview and record review on 6/21/21 at 9 A.M., Resident 36's Dialysis Communication sheets, dated 5/28 to 6/18/21, were reviewed. The ADON stated communication from the dialysis center was completely blank for 6/9, 6/14, 6/16, and 6/18/21, with no indication of weights, vital signs, assessment of the access site, or any other information during the treatment. The ADON stated communication from the dialysis center was important, so they knew if medications were given, the resident's fluid balance, and any change of condition of the resident to appropriately address Resident 36's care and needs.
During the same interview and record review, The ADON stated Resident 36's post-assessments were completely blank for 6/4/21 and 6/14/21, with no indication of weight, vital signs, or assessment of the resident's access site. The ADON stated the post-assessment was important to ensure the resident was stable after their dialysis treatment.
During an interview with the director of nursing (DON) on 6/21/21 at 4:12 P.M., the DON stated she expected the LNs to ensure all sections of the Dialysis Communication sheets were completed, and the dialysis center should have been called or faxed to gather the required information. The DON stated communication between the dialysis center and the facility was important because the LNs needed to know what happened with the resident while out of the facility to ensure they could provide appropriate care for these residents.
According to the facility's policy titled Dialysis, dated 3/20, .This facility assures that each resident receives care and services for the provision of hemodialysis . consistent with professional standards of practice including the: .
•
Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; and
•
Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 3 was readmitted to the facility on [DATE] with diagnoses that include major depression, insomnia (hard to sleep), a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 3 was readmitted to the facility on [DATE] with diagnoses that include major depression, insomnia (hard to sleep), anxiety disorder and manic episode without psychotic (mental disorders that cause abnormal thinking and perceptions) symptoms per the facility's admission Record.
A review of Resident 3's Minimum Data Set (MDS - an assessment tool), dated 5/28/21, indicated that Resident 3 had a Brief Interview for Mental Status (BIMS - a test used to assess a person's mental status) score of 15, which meant that Resident 3's mental status was intact.
On 6/15/21 at 11:38 A.M., an interview with Resident 3 was conducted. Resident 3 stated that he was taking medications that made him drowsy and sleepy.
A review of Resident 3's physician orders included the following medications with their side effects:
1. Lacmictal (a medication used to help with moods) 25 milligrams (mg) - give 75 mg by mouth at bedtime for Bipolar D/O (mental disorder) to be started on 6/14/21. Side effects of the medication included sedation, blurred vision, and increased depression with lack of motivation.
2. Trazodone HCL (a medication used to help with depression) tablet 50 mg - give one tablet by mouth at bedtime for depression to be started on 4/20/21. Side effects of the medication included sedation, drowsiness, and blurred vision.
3. Duloxetine HCL (a medication used to help with depression) 60 mg - give one capsule by mouth for depression to be started 11/29/20. Side effects of the medication included sedation, drowsiness, and blurred vision.
A review of Resident 3's eMAR (electronic Medication Administration Record) was conducted. The eMAR from April 2021 to June 2021 showed no documentation that Resident 3 exhibited side effects from the use of the psychotropic medications (medications used to control mood and behavior).
A review of Resident 3's care plan was conducted. The care plan indicated that Resident 3 was taking psychotropic medications and that the goal was for the resident to be free from discomfort or adverse reactions. The care plan interventions included, observe for side effects, effectiveness, and report as needed any adverse reactions.
On 6/17/21 at 11:42 A.M., an interview with Certified Nursing Assistant (CNA) 9 was conducted. CNA 9 stated Resident 3 had been drowsy at times.
On 6/18/21 at 3:15 P.M., an interview with Resident 3 was conducted. Resident 3 stated he felt tired, drowsy, and sleepy. Resident 3 stated he thought his medications were causing the problem. Resident 3 stated that one time, he heard the CNA and the LN trying to wake him up, but he had a hard time waking up.
On 6/21/21 at 1:10 P.M., an interview with LN 10 was conducted. LN 10 stated, she knew Resident 3 well. LN 10 stated Resident 3 was usually sleepy and drowsy in the morning.
On 6/21/21 at 1:18 P.M., an interview with Director of Staff Development (DSD) was conducted. The DSD stated the LNs should have monitored and identified Resident 3's drowsiness as a possible side effect from the psychotropic medications the resident was taking. The DSD stated it was important to monitor the resident for medication side effects and to communicate their observations to the resident's physician in order for the physician to determine whether the medication needed to be adjusted.
On 6/21/2021 at 4:15 P.M. an interview with the Director of Nursing (DON) was conducted. The DON stated it was important for the LNs to monitor the residents for psychotropic medication side effects and to communicate the side effects observed to the physician in order for the physician to determine whether an appropriate adjustment of the medication was needed.
A review of the facility's policy titled Behavior Assessment and Monitoring, revised 4/2007 indicated, . Highlights . Monitoring for side effects of Psychoactive Medications: . 3. The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling .
Based on observation, interview, and record review, the facility failed to ensure the target behaviors were appropriate and side effects were monitored for the use of psychotropic (affecting mental activity) medications for two of 5 residents (Residents 36 and 3) reviewed for unnecessary medications.
Failure to monitor appropriate target behaviors for Resident 36 had the potential to affect the ordering physician's ability to determine the effectiveness of the medication. In addition, Resident 3 experienced drowsiness that was not identified and reported to the resident's physician.
Findings:
1. Resident 36 was admitted to the facility with diagnoses, which included unspecified dementia (impaired ability to remember, think, or make decisions that interfere with everyday activities), per the facility's admission Record.
During a phone interview with Resident 36's responsible party (RP) on 6/17/21 at 9:04 A.M., the RP stated Resident 36, Can get agitated and combative at times.
According to Resident 36's physician's order, dated 2/11/21, the resident was monitored for behavioral disturbances evidenced by shouting out, refusal of care, and aggressive behavior.
During a concurrent interview and record review with the assistant director of nursing (ADON) on 6/18/21 at 10:55 A.M., the ADON stated behavior monitoring was a way to tell if a resident's medication was working or not. The ADON stated refusal of care was not a behavior that indicated the use of psychotropic medications. The ADON stated since multiple behaviors were monitored for Resident 36, it was unclear if the monitored behaviors were the behaviors indicated for the medication.
During a phone interview with the facility's pharmacy consultant (PC) on 6/21/21 at 3:32 P.M., the PC stated behavior monitoring helped to inform the facility how a psychotropic medication was working. The PC stated residents should be monitored for behaviors that pose harm to self or others and be related to the indication of the medication.
During an interview with the director of nursing (DON) on 6/21/21 at 4:15 P.M., the DON stated the purpose of behavior monitoring was to know if the psychotropic medication was effective. The DON stated monitored behaviors needed to be specific and related to the medication indications so they could decide if the dosages or medications needed to be changed. The DON stated refusal of care was not an indication for medication because the resident had a right to refuse care.
According to the facility's policy titled Psychotropic Medication Use, dated 12/07, . 7. All medication used to treat behaviors must have a clinical indication . All medications used to treat behaviors should be monitored for: 7.1 Efficacy . 7.3 Benefits . 12. Facility staff should monitor the resident's behavior pursuant to Facility policy .
According to the facility's undated policy titled Behavior Assessment and Monitoring, .Monitoring: 2. The staff will document . information about specific problem behaviors or moods. 3. Interventions will be adjusted based on the impact on behavior and other symptoms .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the faility failed to ensure that IV tubing was labeled apropriatly for two o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the faility failed to ensure that IV tubing was labeled apropriatly for two of 30 sampled residents [199 and 200].
Findings:
During the initial tour of the facility 06/15/21 at 3:30 P.M., Resident 199, was observed in bed, with a peripheral inserted catheter (PIV.) in her right hand. There was no date, time, RN initials when inserted, or the size of the needle inserted into Resident 199. At the bedside was an IV pole with IV antibiotics hanging on the IV pole, there was no label on the tubing to indicate when the tubing was hung.
During a subsequent interview on 6/15/2021 at 3:46 P.M., with RN 32. RN 32 acknowledged that, there is no date or RN signature of who started the PIV or the size of the needle. RN 33 further stated there was no label on the tubing letting other RN's know when the IV tubing was hung or when to replace the tubing.
During an interview and record review with RN 33, on 06/17/21, at 3:54 P.M., RN 33, stated we change peripheral IV sites every 72 hours and put on the occlusive dressing (air and water tight trauma medical dressing used in first aid) our initials, date and needle size on the dressing then we put in a care plan.
Resident 200 was admitted to the facility on [DATE] with the diagnoses to include type 2 diabetes (DM - chronic condition that affects the way the body processes blood sugar).
During the initial tour of the facility 06/15/21 at 4 P.M., Resident 200 was observed sitting in a wheelchair watching TV. There was an IV pole behind Resident 200, with an IV bag hanging unattached from the IV machine. The 100 ml of NS bag had Cefezolin 1 gm written in black sharpie on the side of the bag.
During a subsequent interview with RN 31, she stated this in not correct, there should be a name of the patient on the bag, the name of the nurse and when hung and a label on the IV tubing that states when the IV tubing was put up and when the IV tubing should be changed.
During a review of the facility's policy and procedure (P & P) titled, Labeling of infusions, revised 5/1/15, indicated, .Guidance .Label should include, but is not limited to .Patient's name .IV solution/volume/diluent .Medication dose .Route and rate .Date and time of administration .Initials of nurse preparing/administering medication .
On 6/18/21 10:15 A.M., with DON. The DON stated I would expect the IV bag being hung to have Resident's 200 name, date and time the IV was hung and the and the nurse's initials on the bag. The IV tubing should also have a label placed that has the time and date the tubing was hung.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0775
(Tag F0775)
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 have laboratory reports filed in the resident's clinical record for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have laboratory reports filed in the resident's clinical record for one of three residents (Resident #31).
As a result, the nursing staff was unable to properly assess if Resident 31 had abnormal laboratory results that had the potential for Resident 31 not to receive competent medical interventions if needed.
Findings:
Resident 31 was admitted to the facility on [DATE] with diagnoses that include ileus (intestine that gets twisted inside the body causing severe pain and potential blockage), gastrointestinal hemorrhage (bleeding inside the intestine or stomach), muscle weakness and heart disease, per the facility's admission Record.
On 06/18/21 at 10:35 A.M., a record review was conducted. The record indicated that Resident 31 had blood laboratory (lab) orders from the physician on 6/3/21 that included a complete blood count (CBC), basic metabolic panel (BMP) and thyroid stimulating hormone (TSH) with reflex. There was no documented evidence of any lab results for blood labs that were ordered on 6/3/21.
On 06/18/21 at 10:46 A.M., an interview and concurrent record review was conducted with licensed nurse (LN) 10. LN 10 stated she could not locate laboratory (lab) results for Resident 31 in the medical record for blood labs that were ordered on 6/3/21. LN 10 stated the facility typically gets lab results in 24-48 hours for basic blood samples. LN 10 stated the blood labs that were ordered for Resident 31 on 6/3/21 were basic blood labs.
On 06/18/21 at 10:55 A.M., an interview was conducted with LN 5. LN 5 stated it is important to have resident laboratory (lab) results in the medical record as soon as possible so the nurses could contact the physician if the results are abnormal. LN 5 stated it was also important for lab results to be in the residents' medical record because it could be helpful when a LN is assessing a resident that may be ill.
On 06/18/21 at 3:20 P.M., an interview and document review were conducted with Licensed Nurse (LN) 10. LN 10 presented a document with Resident 31's laboratory (lab) results that were drawn (blood taken from the body to obtain a laboratory specimen) on 6/7/2021 and ordered on 6/3/21 that only included a thyroid stimulating hormone (TSH) result and did not include the CBC and BMP that was also ordered by the physician on 6/3/21. LN 10 stated she had to obtain the TSH result from a nurse practitioner that worked in the facility downstairs because the nurses on the unit could not access the system used to view resident lab results. LN 10 stated the nurse practitioner was unable to access the results of the other lab results (CBC and BMP) that was ordered on 6/3/21 for Resident 31 at this time. LN 10 stated the facility was unable to obtain all of Resident 31's lab results that were ordered on 6/3/21 at this time. LN 10 stated if the 6/3/21 lab results were not in the resident's chart, they were not received on the nursing unit.
On 06/21/21 at 4:35 P.M., an interview was conducted with the facility's Director of Nursing (DON). The DON stated it was her expectation that laboratory results would be in the medical record (MR) for all residents by the next day after labs are drawn. The DON stated if lab results were not available in the MR the nurses would not be able to follow the physician's orders for medication ranges or monitoring and that could be detrimental to the health of the residents.
A document review was conducted. Document titled Diagnostic Services dated 5/14/2020, indicated, .Test Results . 5. Signed and dated reports of these services are entered in the resident's medical record .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
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 coordinate dental services as ordered for one residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to coordinate dental services as ordered for one resident (Resident 50).
As a result, Resident 50 did not get her ordered dentures and was at risk for choking, poor nutrition, and potential loss of dignity.
Findings:
Resident 50 was readmitted to the facility on [DATE] with diagnoses that include deficiency (lack of) of B group vitamins, aphasia (loss of ability to express speech caused by brain damage), and cerebral infarction (lack of blood supply to the brain causing brain damage) affecting the left dominant side (left side of body), per the facility's admission Record.
On 06/15/21 at 11:01 A.M., an observation and interview were conducted with Resident 50. Resident 50 appeared to have no top teeth when observed during interview. Resident 50 stated she had no dentures but would like some very much. Resident 50 stated she had no top teeth and only a few bottom teeth. Resident 50 smiled and said, that would be great if I could get dentures.
On 06/17/21 a review of Resident 50's medical record (MR) and electronic medical record (EMR) was conducted. There was no documented evidence that the facility obtained informed consent or coordinated an appointment for Resident 50 to get dentures per the dental order that was written 9/10/2019. The EMR in section, Progress Notes, indicated on 9/10/2019, Progress note received from dental office, TAR (Treatment Authorization Request) pending for upper dentures. The EMR indicated Resident 50 was on a regular diet with thin liquids per the medical doctor's order. The EMR indicated in the Minimum Data Set Assessment (MDS -assessment tool), section L, that resident had her own teeth on admission date 2/23/18 and in the last quarterly assessment 4/30/21 the resident had cracked and broken natural teeth. The EMR or MR did not indicate that resident was admitted with dentures.
On 06/18/21 at 3:06 P.M., an interview was conducted with Resident 50. Resident 50 stated she had dentures when she first came to the facility, but they lost them.
On 06/18/21 at 3:29 P.M., an interview and document review were conducted with the facility's Director of Staff Development (DSD) and the Director of Social Services (DSS). The DSD presented a type written piece of paper with no resident identifier or date on it that also had a handwritten statement in pencil at the bottom of the page. The DSD stated the document was created by the Social Service Assistant today. The document had dates and times that Resident 50 was evaluated by a dentist and documentation that the Resident's Responsible Party (RP) refused to give approval for dentures. The handwritten documentation on the document in pencil indicated on 6/18/21 that a stat dental appointment was made for Resident 50. The DSS and DSD stated the type written and pencil written document presented was not an official facility document with a proper resident identifier. The DSS stated he would try to locate documentation in Resident 50's medical record supporting the information that was presented in the document.
Resident 50's RP was not available for interview.
On 06/21/21 at 10:59 A.M., an interview and concurrent record review were conducted with the facility's Director of Staff Development (DSD) and Director of Social Services (DSS). The DSS stated the facility's Social Service Assistant did not document any discussions she had with Resident 50 or Resident 50's RP anywhere in the resident's medical record in regards to obtaining consent for dentures. DSS stated the Social Service Assistant told him she forgot to document it. The DSD stated there was no careplan related to dental or dentures in Resident 50's medical record. The DSS and the DSD stated all residents admitted to the facility that did not have teeth should have had an initial and ongoing careplan addressing the needs of the resident. The DSD stated she could not locate in Resident 50's medical record an initial or ongoing careplan related to resident not having teeth. The DSD stated she could not locate any documentation in Resident 50's medical record where the facility's registered dietitian noted that the resident did not have any teeth.
On 06/21/21 at 4:30 P.M., an interview was conducted with the facility's Director of Nursing (DON). The DON stated it was important that residents have teeth and that the staff follows through with dental orders. The DON stated Resident 50 could be at risk for nutritional deficits if the meals ordered for her did not match the resident's chewing and swallowing ability. The DON stated because Resident 50 did not have teeth she was at risk for choking, significant weight loss or nutritional deficits.
A review of facility policy titled Dental Services dated 5/19/20 indicated, . The facility must assist residents in obtaining routine and 24 hour emergency dental care .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one unsampled resident (Resident 23) had his f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one unsampled resident (Resident 23) had his food allergies, dislikes, and preferences clearly identified. In addition, some nursing staff could not identify a dislike from a food allergy.
This failure had the potential to cause harm if a food allergy was served to a resident by mistake.
Findings:
Resident 23 was admitted to the facility on [DATE], per the facility's admission Record.
On 6/15/21 at 11:59 A.M., an observation of resident dining was conducted in the second floor dining room. Resident 23 was observed eating cottage cheese. Resident 23's meal ticket dated 6/15/21, indicated, .Allergies/dislikes .cheese cottage . Preferences . Cottage cheese Resident 23 stated he liked cottage cheese.
On 6/15/21 at 12:05 P.M., a joint interview and record review was conducted with licensed nurse (LN) 5. LN 5 reviewed Resident 23's meal ticket dated 6/15/21 and stated cottage cheese was listed as both an allergy/dislike and a preference on the resident's meal ticket. LN 5 stated allergies/dislikes and preferences should have been made clear on Resident 23's meal ticket.
On 6/17/21 at 10:52 A.M., a joint interview and record review was conducted with the director of dietetic services (DDS). The DDS acknowledged Resident 23's allergies/dislikes should have been clearly differentiated from preferences. The DDS stated the facility identified true food allergies with an encircled A next to the food listed under a resident's allergies/dislikes. The DDS showed a sample of resident tickets that had food allergies identified with an encircled A. The DDS stated true food allergies had to be clearly known because serving a food allergy to a resident could hurt the resident.
A review of Resident 23's meal ticket dated 6/15/21, indicated, .Allergies/Dislikes [:] Beef, cheese cottage, chicken, cucumber salad, fish, tofu, turkey None of the food was identified with an encircled A.
On 6/21/21 at 9:05 A.M., a joint interview and record review was conducted with assistant director of nursing (ADON). The ADON reviewed Resident 23's meal ticket dated 6/15/21, and stated she could not identify which food was an allergy from a dislike.
On 6/21/21 at 9:12 A.M., a joint interview and record review was conducted with restorative nursing assistant (RNA) 2. RNA 2 reviewed Resident 23's meal ticket dated 6/15/21, and stated she could not identify if one of the allergies/dislikes was a true food allergy from a dislike. RNA 2 stated, There are multiple things on this ticket. It is hard to distinguish.
On 6/21/21 at 9:18 A.M., a joint interview and record review was conducted with certified nursing assistant (CNA) 10. CNA 10 reviewed Resident 23's meal ticket dated 6/15/21, and stated she was unable to distinguish the resident's allergy from a dislike. CNA 10 stated it looked like the resident was allergic to or disliked many things.
On 6/21/21 at 2:52 P.M., an interview was conducted with facility's registered dietitian (RD). The RD stated it was important for nursing to be able to readily identify a resident's food allergy from a dislike. The RD stated nursing was the final safety check to ensure a resident was not provided a food allergy by mistake. The RD stated a resident could be harmed if they were served a food they were allergic to. The RD stated all nursing staff needed to know food allergies were coded on the meal tickets by an encircled A next to the food item.
On 6/21/21 at 3:34 P.M., an interview was conducted with the facility's administrator and the director of nursing (DON). The DON stated all nursing staff should have been able to verbalize how to identify a food allergy from a dislike. The DON stated it was the responsibility of nursing staff to ensure residents had access to safe food.
A review of the facility's policy titled Food Allergies and Intolerances, revised 11/28/17, indicated, .Food allergies and intolerances are communicated to Nursing Services and indicated on the resident tray card and resident profile . Foodservice and nursing associates are educated on food allergies and intolerances
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure the residents' refrigerator on Station 2 was maintained in a clean and sanitary condition.
This failure had the poten...
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Based on observation, interview, and record review, the facility failed to ensure the residents' refrigerator on Station 2 was maintained in a clean and sanitary condition.
This failure had the potential to expose the residents' food to unclean conditions.
Findings:
On 6/17/21 at 10:37 A.M., a joint observation of the residents' refrigerator on Station 2 was conducted with certified nursing assistant (CNA) 9. The residents' refrigerator had food stored inside that visitors and family brought in for the residents as well as snacks that were provided by the facility. The surface of the refrigerator's bottom shelves were heavily stained with dried-on brownish liquid, small pieces resembling food debris, and a loose piece of crumpled plastic wrap. The inside of the bottom drawers had dried golden stains, and small particles resembling food debris. CNA 9 stated the residents' refrigerator was dirty and the stains looked old. CNA 9 stated she did not know who was responsible for maintaining the cleanliness of the inside of the residents' refrigerator. CNA 9 stated this was the residents' home and their refrigerator should not look like that. Affixed to the wall next to the refrigerator was a cleaning schedule that indicated the inside of the refrigerator was last cleaned on 6/9/21.
On 6/17/21 at 3:14 P.M., an interview was conducted with the director of staff development (DSD). The DSD stated the residents' refrigerator on Station 2 should have been maintained in a cleanly manner. The DSD stated not maintaining the refrigerator in a cleanly manner was an infection control concern.
On 6/18/21 at 11:45 A.M., a joint observation of the residents' refrigerator on Station 2 was conducted with the housekeeping manager (HM). The inside of the residents' refrigerator had been wiped clean. The HM stated she had seen the inside of the residents' refrigerator on 6/17/21 and that it had not been in a clean and sanitary condition. The HM stated the inside of the residents' refrigerator was scheduled to be cleaned once a week. The HM stated the outside of the refrigerator was cleaned daily. The HM stated the inside of the refrigerator should be checked daily and cleaned as needed in addition to a once a week cleaning. The HM stated the inside and outside of the residents' refrigerator should be maintained in a clean condition everyday.
The facility's policy titled Cleaning Schedule dated 10/14/19, did not provide guidance related to maintaining the residents' refrigerator.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 21 sampled residents' (Resident 17) med...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 21 sampled residents' (Resident 17) medical record was accurate, when a licensed nurse (LN) documented a wound treatment as done, when the treatment to the resident's wound was not performed.
This failure had the potential to cause miscommunication of Resident 17's wound treatment to the other health care providers.
Findings:
Resident 17 was readmitted to the facility on [DATE] per the facility's admission Record.
During an observation on 6/16/21 at 9:23 A.M., Resident 17 had a wound dressing on his right hand with a date of 6/8 written on the dressing.
A record review was conducted. The physician's order dated 6/7/21, indicated, Right hand abrasion: cleanse with NS (Normal saline), pat dry, apply dry dressing, every day shift every 3 days.
Resident 17's June 2021 eTAR (electronic Treatment Administration Record - a record where nurses mark treatment was done) was reviewed. The June 2021 eTAR indicated the resident's wound treatment for his right hand abrasion had been initialed as done on 6/8/21, not initialed on 6/11/21, and was initialed on 6/14/21 as done by LN 10.
On 6/18/21 at 11:11 A.M., an interview with LN 10 was conducted. LN 10 stated on 6/14/21, she marked the eTAR with her initials without changing Resident 17's right hand dressing.
On 6/21/21 at 1:36 P.M., an interview with the Director of Staff Development (DSD) was conducted. The DSD stated accurate documentation in Resident 17's eTAR was important for proper communication of the care provided.
On 6/21/21 at 3:14 P.M., an interview with the Director of Health Information (DHI) was conducted. The DHI stated the facility did not have a policy and procedure related to medical record accuracy. The DHI stated staff were expected to accurately document in the residents' medical records.
On 6/21/2021 at 4:18 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated LN 10 should not have marked the eTAR with her initial without changing Resident 17's right hand dressing. The DON stated it was important for medical records to be accurate to avoid miscommunication of care.
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** Based on observation, interview, and record review, the facility failed to fully implement infection control standards of practi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to fully implement infection control standards of practice when hand hygiene was not performed between glove changes during a wound treatment observation on 1 of 30 sampled residents (Resident 398).
This failure had the potential for an increase in facility-acquired infection and medical complications for Resident 398.
Findings:
Resident 398 was admitted to the facility on [DATE] with diagnoses including surgical aftercare following surgery on the digestive system per the facility's admission Record.
According to a physician order dated 6/8/21, Resident 398 was to have her abdominal wound cleansed three times a week; with white sponge applied to wound undermining (pockets at the wound edge) and black sponge to fill wound and wound VAC (vacuum-assisted closure: a method of decreasing air pressure around a wound to assist the healing).
According to Resident 398's Wound Observation Tool, dated 6/14/21, the resident's abdominal wound was 6 centimeters (cm) long, 2.0 cm wide, and 2.0 cm deep, with tunneling (undermining) at the edges measuring from 1.0 cm to 6.8 cm.
The wound treatment nurse (tx nurse) was observed during Resident 398's wound treatment on 6/17/21 from 10:09 A.M. to 10:44 A.M. The tx nurse washed her hands multiple times before starting the procedure. At 10:20 A.M., after turning off the wound VAC and clamping the tubing, the tx nurse donned clean gloves and removed the wound dressing. Without changing gloves, the tx nurse poured a wound cleansing solution onto the black sponge and then used a clean cotton swab to dislodge and remove the black sponge. Next, the tx nurse used her gloved hand to remove the white sponge at the wound base. At 10:24 A.M., the tx nurse removed her gloves, donned clean gloves without doing hand hygiene, and cleaned Resident 398's wound. At 10:26 A.M., after measuring the wound's undermining, the tx nurse removed her gloves without doing hand hygiene and donned clean gloves. The tx nurse continued with the wound treatment, shaping, and placing the white sponge at the base edges of the wound, then applying the black sponge to fill the wound before applying a new dressing and wound VAC. The tx nurse completed the procedure at 10:43 A.M., then washed her hands at the sink.
During an interview with the tx nurse on 6/17/21 at 10:45 A.M., the tx nurse stated she did not do hand hygiene between glove changes. Tx nurse stated she thought hand hygiene was not required because changing her gloves removed the germs.
During an interview with the director of nursing (DON) on 6/17/21 at 11 A.M., the DON stated she expected staff to adhere to infection control standards and perform hand hygiene between all glove changes. The DON further stated it was essential to do hand hygiene when moving from dirty to clean tasks when changing dressings and not introducing any organisms back into the wound.
According to the facility's policy titled Wound Care Treatment Clean Dressing Change, dated 10/20, Intent- To perform a non-sterile dressing application in a manner to cleanse the wound to remove non-adherent debris, preventing grossly cross-contaminating the wound and to prevent introducing new bacteria into the wound bed. Procedure: .5. Remove the soiled dressing and place in bag for disposal. 6. Remove your gloves and discard them. 7. Follow hand hygiene protocol. 8. Put on new gloves. 9. Cleanse the wound as directed. 10. Remove your gloves and discard them. 11. Follow hand hygiene protocol. 12. Put on new gloves and perform wound care as ordered .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 3 was readmitted to the facility on [DATE] with diagnoses that include quadriplegia (paralysis of all four limbs) an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 3 was readmitted to the facility on [DATE] with diagnoses that include quadriplegia (paralysis of all four limbs) and neuromuscular dysfunction (a diseases affecting the function of muscles due to problems with the nerves and muscles in the body) of the bladder per the facility's admission Record.
A review of Resident 3's Minimum Data Set (MDS - an assessment Tool), dated 5/28/21, indicated Resident 3 had a Brief Interview for Mental Status (BIMS - a test used to assess a person's mental status) score of 15, which meant that Resident 3's mental status was intact. Per the same MDS, Resident 3 was totally dependent on staff for toileting.
On 6/15/21 at 11:38 A.M., an interview with Resident 3 was conducted. Resident 3 stated staff were not answering the call lights in a timely manner. Resident 3 stated that two days ago, she used the call light because she needed assistance, but the staff never came. Resident 3 stated sometimes it took an hour or more before a staff answered her call light.
5. Resident 25 was readmitted to the facility on [DATE] with diagnoses that include of Traumatic brain injury (sudden injury that causes damage to the brain per the resident's admission Record.
A review of Resident 25's Minimum Data Set (MDS - an assessment tool), dated 3/30/21, indicated Resident 25 had a Brief Interview for Mental Status (BIMS - used to assess a person's mental status) score of 14, which meant that Resident 25's mental status was intact. The MDS also indicated Resident 25 needed extensive assistance with toileting.
On 6/15/21 at 3:48 P.M., an interview with Resident 25 was conducted. Resident 25 stated she used a bell, that she could tap to call staff, because she was not able to use the call light button due to weakness on both of her arms and hands. Resident 25 stated that sometimes staff did not answer her call light timely that she would end up wetting herself.
6. Resident 17 was readmitted to the facility on [DATE] per the resident's admission Record.
A review of Resident 17's Minimum Data Set (MDS - an assessment tool), dated 3/11/21, indicated that Resident 17 had a Brief Interview for Mental Status (BIMS - used to assess a person's mental status) score of 10, which meant that Resident 17 had moderate impairment in mental status. Per the same MDS, Resident 17 was totally dependent on staff for toileting.
During an observation on 6/16/21 at 9:23 A.M., a wound dressing, with a date of 6/8 written on it, was on Resident 17's right hand.
A record review was conducted. The physician's order dated 6/7/21, indicated, Right hand abrasion: cleanse with NS (Normal saline), pat dry, apply dry dressing, every day shift every 3 days.
Resident 17's June 2021 eTAR (electronic Treatment Administration Record - a record where nurses mark treatment was done) was reviewed. The June 2021 eTAR indicated the resident's wound treatment for his right hand abrasion had been initialed as done on 6/8/21, not initialed on 6/11/21, and was initialed on 6/14/21 as done by LN 10.
On 6/18/21 at 11:11 A.M., an interview with LN 10 was conducted. LN 10 stated, the LNs was supposed to take care of the wounds of the residents assigned to them when the treatment Nurse (TN) was on leave. LN 10 stated she was not able to change the dressing of Resident 10 because she had to take care of about 20 residents. LN 10 stated that she could only change the wound dressing when she had the time. LN 10 stated she tried to do her best to accommodate all residents' wound care when the TN was on leave.
On 6/21/21 at 9:35 A.M., an interview with LN 5 was conducted. LN 5 stated that the TN was a great help for the LNs. LN 5 stated, the LNs could not attend to all the wound care of the residents because the LNs had 25 -27 residents to take care in one shift. LN 5 stated, the facility should have additional TN to take care of the residents' wounds.
A document review was conducted. Undated document titled Answer the Call Light indicated, . 8. Answer the resident's call as soon as possible
A document review was conducted. Document titled Staffing, dated 2/4/2020, indicated, The facility maintains adequate staff on each shift to meet residents' needs .
Based on observation, interview and document review the facility failed to provide sufficient staff to meet the needs of seven residents (Residents 3, 12, 17, 25, 88, and Confidential Residents [CR] 1 and 2).
As a result residents 3, 12, 17, 25, 88, CR 1 and CR 2 did not receive care in a timely manner, putting them at risk for skin break down and creating unnecessary fear. In addition, Resident 17 did not receive wound treatment consistently due to insufficient staffing.
Findings:
1. Resident 88 was admitted to the facility on [DATE] with diagnoses that include surgical aftercare, difficulty walking and muscle weakness, per the facility's admission Record.
On 06/15/21 at 2:50 P.M., an interview was conducted with Resident 88. Resident 88 stated almost every night no one answered his call light in a timely manner. Resident 88 stated many times he had to get himself out of bed, into his wheelchair and then push himself down to the nurse's station to get help with changing of his brief and getting cleaned up. Resident 88 stated he had frequent loose stools due to his medication and had accidents often. Resident 88 stated he could not get himself cleaned or his brief changed by himself. Resident 88 stated many times he had to wait at least a half an hour or more after using the call light before someone would come to help him. Resident 88 stated, It's terrible I have to go through this.
On 06/18/21 at 9:25 A.M., an interview was conducted with Resident 88. Resident 88 stated it was a pain in the butt to go to the nurses' station when the staff did not answer his call light at night. Resident 88 stated the more he had to wait for someone to come help him get cleaned up, the worse his diaper rash gets. Resident 88 stated the nurses at the nurses' station tell him sometimes his CNA is on a break, yet they never said someone else will come help him. Resident 88 stated he sometimes just had to wait for the CNA assigned to him to come back from their break before he could get help. Resident 88 stated, Shouldn't they have someone covering when my CNA is on a break?.
2. Resident 12 was admitted to the facility on [DATE] with diagnoses that included chronic pain, legal blindness (unable to see), osteoarthritis (breakdown of joint cartilage and underlying bone), epilepsy (sudden episodes of abnormal electrical activity in the brain that can cause uncontrolled body movements and loss of consciousness), per the facility's admission Record.
On 06/16/2021 at 8:46 A.M., an interview was conducted with Resident 12. Resident 12 stated she had to call several times, and still no one came to help her. Resident 12 stated, It's not supposed to happen. I'm scared because how can I get to someone if I need help?.
3. On 06/16/21 at 10:08 A.M., interviews were conducted in the Resident Council meeting. A confidential resident stated the certified nursing assistants (CNAs) did not come in a timely manner when the call lights were used. A confidential resident stated they sometimes used the call light in their bathroom instead of by their bed. The confidential resident stated they do that because the call light from the bathroom is louder and the staff would come when that one was used. A confidential resident stated it could take the staff 30 minutes or more before someone came to help. A confidential resident stated one resident yells and hits her table at night when the staff did not come.
A document review was conducted. Document titled Resident Council Meeting Minutes, dated 3/3/21 indicted a confidential resident stated, Call lights not being answered in a timely manner.
A document review was conducted. Document titled, One on One In Room Resident Council dated 4/7/21 indicated a confidential resident stated, PM CNA's not answering call lights right away.
On 06/18/21 at 9:18 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 63. CNA 63 stated she had been educated by the facility to answer all call lights as quickly as possible. CNA 63 stated if call lights were not answered in a timely manner, residents could be left in soiled briefs too long and this could cause skin break down. CNA 63 stated it could also make the resident feel sad if left in a soiled diaper for a long period of time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0841
(Tag F0841)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility's medical director (MD) failed to ensure medical care was provided to residents according to acceptable standards of practice for the f...
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Based on observation, interview, and record review, the facility's medical director (MD) failed to ensure medical care was provided to residents according to acceptable standards of practice for the following:
- Development and Implementation of Care Plans (See F-Tag 656)
- Quality of Care/Treatment (See F-Tag 684)
- Accidents and Hazards (See F-Tag 689)
- Dialysis Assessments (See F-Tag 698)
- Sufficient Nursing Staff (See F-Tag 725)
- Pharmacy Services (See F-Tag 755)
- Medication Errors Greater than Five Percent (See F-Tag 759)
- Lab Reports (See F-Tag 775)
- Medical Records (See F-Tag 842)
- Infection Control (See F-Tag 880)
As a result, resident care was not provided in accordance to the facility policies and procedures, which could potentially result in physical and psychosocial harm to the residents.
Findings:
On 9/8/21 at 9:10 A.M., a telephone interview with the MD was conducted. The MD stated he was aware of results of the facility's re-certification survey completed on 6/21/21. The MD stated he knew there would be a revisit wherein the facility would be expected to be in compliance with their plan of correction (POC) for deficiencies identified during the re-certification survey. The MD stated the facility was experiencing a nursing staff shortage as there had been a mass exodus of nurses. The MD stated the facility was using registry staff (nursing staff provided by an agency) and had several new hires. The MD stated he had some input in the facility's POC and felt the facility was doing their best to monitor and perform audits for POC compliance. The MD stated he felt the facility had done a good job with compliance under the circumstances, but that the facility could not ensure 100 percent of the POC was done due to unprecedented staff turnover. The MD was informed that the facility had areas of repeated noncompliance and that the facility had not fully implemented their POC. The MD stated he thought the past issues related to laboratory results had been fixed. The MD stated he was not aware the issue with laboratory results was ongoing and that the providers were not being informed of lab results. The MD stated he had been unaware that the facility was not following their POC and was not conducting consistent audits for compliance. The facility's issues identified with medication administration were discussed. The MD stated the facility should check the medication administration competency of registry nurses. The MD stated it was important to ensure registry staff were providing care correctly. The MD stated the facility's POC was not fully implemented as there had been so many challenges. The MD stated, Care should have been given to the residents according to acceptable standards of practice.
On 9/8/21 at 2:50 P.M., an interview was conducted with 23 members of the facility's QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) Committee. The interim administrator (IADM) stated after the QAPI/QAA Committee met, the facility would conduct the Medical Director and Facility Oversite Committee which included the medical director, the administrator, and the director of nursing. The IADM reviewed the QAPI/QAA minutes for 7/20/21 and 8/24/21 and stated there was no documentation of the Medical Director Facility Oversight Committee meeting. The IADM stated he would not expect the medical director to raise questions and provide guidance and oversight about POC compliance if the medical director were not made aware of the results of the facility audits and other care issues. The IADM further stated the QAPI/QAA minutes were unclear as to what was specifically discussed during the QAPI/QAA meetings. The IADM stated based on the content of the QAPI/QAA minutes, the medical director would not know what was going on.
A review of the facility policy and procedure titled Medical Director, revised 8/2021, indicated, .The facility will have a designated medical director who is responsible for implementing care policies and coordinating medical care . 2.responsibilities must include .: .Coordinating and planning for improvement of medical care in the facility .Ensuring the appropriateness and quality of medical care and medically related care; . Any issues related to the facility performance improvement, regulatory compliance concerns, and any quality of care or safety issues should be recorded on the Medical Director Facility Oversight Committee Minutes .5. The facility's responsibilities in relation to its medical director include: Working with the medical director to ensure adequate resident care
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure it had an effective QAPI/QAA (Quality Assuranc...
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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 it had an effective QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) program in place to identify and make good faith attempts to correct care issues identified by Resident 81 during a complaint investigation, which included:
- Wound treatments (See F-Tag 684)
- Pharmacy Services (See F-Tag 755)
- Medication Error Rate Greater than Five Percent (See F-Tag 759), and
- Staffing, which was a repeat deficiency identified during the re-certification survey conducted on 6/15/21 through 6/21/21 (See F-Tag 725).
As a result of this deficient practice, systemic care issues were identified by the survey team during a revisit conducted on 9/1/21 through 9/8/21. These failures had the potential to impact the quality of care delivered to all residents.
Findings:
Resident 81 was readmitted to the facility on [DATE], and was her own responsible party, per the facility's admission Record.
On 8/10/21 at 1:10 P.M., an interview was conducted with Resident 81 during the investigation of a complaint. Resident 81 stated the facility was providing medications to the residents late and at times residents were given the wrong medication or wrong dosage. Resident 81 stated there was no treatment nurse on Saturdays and that her treatments were not consistently being done. Resident 81 stated the facility had a staffing problem as it was difficult to get help when you needed it. Resident 81 described all shifts as having a staffing problem. Resident 81 stated she was interested in sharing these concerns with the administrator (ADM) and director of nursing (DON).
On 8/10/21 at 2:22 P.M., a joint interview was conducted with Resident 81, DON, and ADM. Resident 81 told the ADM and DON of her concerns regarding receiving late and incorrect medications, not receiving consistent treatments, and not receiving help in a timely manner. The ADM and DON told Resident 81 that her concerns would be thoroughly looked into and investigated.
On 9/3/21 at 9:10 A.M., an interview was conducted with the director of nursing (DON). The DON stated the facility's staffing was a problem. The DON stated he was aware the nurses' workloads were different on the first and second floors. The DON stated he was aware nurses on the first floor averaged 18-19 residents each and they had a supervisor on the unit while the second floor nurses averaged 27-28 residents each and were without a supervisor. The DON stated nurse workloads and resident acuity levels (the amount of care a resident required) had not been reviewed in order to facilitate timely medication administration, consistent treatments, and more efficient responses to resident needs.
On 9/7/21 at 12:25 P.M., an interview was conducted with the director of staff development (DSD). The DSD stated staffing has been an issue. The DSD stated the facility should have discussed nurse workload and resident acuity to help ease the current staffing burden.
On 9/7/21 at 4:10 P.M., another interview was conducted with the DON. The DON stated he was informed and aware of Resident 81's concerns on 8/10/21 regarding late and incorrect medication administration, treatments not being provided, and not getting help timely. The DON stated more should have been done after he received Resident 81's complaints about medication administration, treatment, and staffing on 8/10/21. The DON stated Resident 81's concerns should have been looked into more thoroughly.
On 9/8/21 at 2:50 P.M., an interview was conducted with 23 members of the facility's QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) Committee. The interim administrator (IADM) and social services director (SSD) both stated the QAPI/QAA used resident grievances, feedback from resident council, and resident complaints as methods for identifying care issues for the QAPI/QAA program to respond to. The IADM stated Resident 81's care concerns should have been identified by the QAPI/QAA Committee and acted upon for performance improvement. The IADM stated the QAPI/QAA Committee had room for improvement.
A review of the facility's policy titled Quality Assessment and Assurance Committee Roles and Responsibilities, dated 12/2019, indicated, .4. The QAA committee must meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues .Develop and implement appropriate plans of action to correct identified quality deficiencies
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to identify, develop, and implement action plans related to the following:
1....
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Based on observation, interview, and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to identify, develop, and implement action plans related to the following:
1. Baseline care plans were not consistently developed to address resident diagnoses, care, and treatments. (cross reference F-Tag 655)
2. Resident specific care plans were not consistently developed. (cross reference F-Tag 656)
3. There was not sufficient staffing to respond to resident requests in a timely manner. (cross reference F-Tag 725)
These failures had the potential to affect the health and safety of the residents.
Findings:
On 6/21/21 at 3:34 P.M., an interview was conducted with the facility's administrator (ADM) and the director of nursing (DON) regarding the facility's QAA committee. The ADM stated the QAA committee met monthly and identified concern areas through multiple sources, which included resident council meetings, employee and resident family feedback, daily meetings, and use of the facility's hotline. The ADM stated the QAA committee was working on three areas of concern which included PPE (personal protection equipment such as masks and gloves), the use of PPE by outside vendors (transport staff and etc.), and employees who refused COVID-19 (respiratory illness) testing. The following concerns identified during the facility's recertification survey (6/15/21 through 6/21/21) were discussed with the ADM and the DON:
1. Resident 71's baseline care plan did not include urinary catheter (tube inserted into the bladder to drain urine) care. Resident 199's baseline care plan did not include peripheral intravenous (catheter inserted into a vein) care and did not include the resident's antibiotic treatment. Resident 200's baseline care plan did not include the resident's diabetes (body's inability to use glucose) diagnosis (see F-Tag 655). The DON stated specific nurses should have been assigned to audit care plans and the data should have been reviewed and discussed during the monthly QAA meetings. The DON and ADM stated care plans should have been identified as a facility QAA study.
2. Resident 75 did not have a resident-specific care plan developed to include the resident's preferences related to incontinence (the inability to control urine or feces) care. Resident 50 did not have a resident-specific care plan developed related to dental care. Resident 32 did not have a resident-specific care plan developed related to preventing the accident of choking (See F-Tag 656). The DON stated specific nurses should have been assigned to audit care plans and the data should have been reviewed and discussed during the monthly QAA meetings. The DON and ADM stated care plans should have been identified as a facility QAA study.
3. Resident complaints that the residents' calls for assistance were not addressed timely. The resident council meeting minutes indicated that the council voiced concern that call lights were not answered timely and care had not been provided in a timely manner (See F-Tag 725). The ADM stated answering call lights and responding to resident requests timely had been discussed in daily stand-up (staff meetings) and the issue had been considered resolved. The ADM stated this issue should have been identified by QAA committee and selected as a QAA study.
A review of the undated facility document titled Quality Assessment Performance Improvement Plan, indicated, . The QAA committee will review data, suggestions, and input from residents, families, and staff. The committee will prioritize opportunities for improvement and will determine which performance improvement projects will be initiated . The QAA committee will prioritize project topics based on the current needs of the residents and facility
Sept 2019
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respectful care for one of three residents (3...
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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 respectful care for one of three residents (317) reviewed for dignity.
This failure had the potential to negatively impact Resident 317's psychosocial well-being.
Findings:
Resident 317 was admitted to the facility on [DATE], per the facility's admission Record.
On 9/12/19, a review of Resident 317's MDS (health status screening and assessment tool), Section C, dated 9/11/19, indicated Resident 317's BIMS Score (test for cognitive function) was 15. A score of 13-15 indicated cognition was intact.
On 9/9/19 at 10:15 A.M., an interview with Resident 317 was conducted. Resident 317 stated some nurses ignore me; I think they don't like me.
On 9/11/19 at 8:50 A.M., an observation was conducted in Resident 317's room. Resident 317 was lying in bed, and asked CNA 11 to help him sit up straight in bed. CNA 11 stated she would ask for assistance from another CNA to help, and left Resident 317's room. After a few minutes, CNA 11 and CNA 12 entered Resident 317's room, without speaking to the resident. CNA 12 did not speak to Resident 317 nor inform Resident 317 when CNA 12 lowered the resident's bed. Without speaking to Resident 317, CNA 11 and CNA 12 then lifted his body (using a draw sheet) towards the head of the bed. CNA 12 then left Resident 317's room without speaking.
On 9/11/19 at 9 A.M., an interview with Resident 317 was conducted. Resident 317 stated when nursing staff does speak to him when providing care, it does not feel good and stated I just want to feel like I am somebody.
On 9/11/19 at 9:10 A.M., an interview with CNA 11 was conducted. CNA 11 stated when providing care, nursing staff should explain why they were in the resident's room, and what they were going to do for a resident before providing the care. CNA 11 stated she should have explained to Resident 317 they were going to pull him up in bed.
On 9/11/19 at 9:28 A.M., an interview with CNA 12 was conducted. CNA 12 stated CNAs should explain what they were doing the entire time they were providing care to make sure the residents and staff were in agreement.
On 9/11/19 at 9:32 A.M., an interview with LN 11 was conducted. LN 11 stated all nursing staff should explain what they were doing, and continue to communicate with the resident the entire time they were providing care.
On 9/12/19 at 12:08 P.M., an interview with the DON was conducted. The DON stated nursing staff were expected to explain and communicate to residents prior to providing care and during care. The DON stated residents should be treated with respect. The DON further stated communicating with residents reassured and comforted them.
According to the facility's policy, titled Dignity, dated May 2019, .Each resident has the right to be treated with dignity and respect .10. Staff and volunteers must interact with residents in a manner that takes into account the physical limitations of the resident, assures communication, and maintains respect .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an appropriate call light device was provided ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an appropriate call light device was provided to one of 26 residents (9) reviewed for accommodation of needs.
This failure resulted in Resident 9 being unable to call for assistance when Resident 9 required help.
Findings:
Resident 9 was re-admitted to the facility on [DATE], with diagnoses which included generalized muscle weakness, difficulty walking, and fracture of the right index finger.
On 9/9/19 at 10:01 A.M., Resident 9 was observed asleep. A soft push call-button was placed on Resident 9's lap.
On 9/9/19 at 11:39 A.M., an observation and interview with CNA 21 was conducted. CNA 21 stated, Resident 9 made needs known to him by yelling out. Resident 9 attempted to press down on the push call-button with the heel of her left hand, but was weak and unable to activate the push call-button. Resident 9 was not able to bend and use her fingers to activate the push call-button.
On 9/11/19 at 2:57 P.M., an interview with CNA 21 was conducted. CNA 21 stated Resident 9 was able to use the push call-button before, but the resident had bad days when she was weaker than usual. CNA 21 stated Resident 9 may have had the push call-button for at least a year. CNA 21 stated he was concerned when Resident 9 could not activate the push call-button. CNA 21 stated, he felt bad, because there could have been times when she tried to use the push call-button, but could not.
On 9/12/19 at 7:05 A.M., an interview with CNA 21 was conducted. CNA 21 stated, the nurses determined the type of call-button suited for the residents.
On 9/12/19 at 10:22 A.M., an interview with LN 22 was conducted. LN 22 stated, the type of call-button depended on the functionality of the resident's hands. LN 22 stated, CNAs were more likely to notice a resident's decline in function, and should report to the LNs. LN 22 stated, the LNs assessed the residents to determine the appropriate call-button.
LN 22 stated it was important for residents to have the appropriate call-button, in order for them to notify staff of their needs, and in emergencies.
LN 22 stated he did not know how long Resident 9 had the push call-button, but a touch-pad call-button was indicated for residents who could not bend their fingers.
On 9/12/19 at 10:42 A.M., an interview with LN 21 was conducted. LN 21 stated Resident 9 had the push call-button for at least six months. LN 21 further stated, a month ago, Resident 9 had a surgical procedure on her left upper arm, and since then it had been painful for Resident 9 to use her left arm. LN 21 stated a touch-pad call-button was more appropriate for Resident 9.
A review of Resident 9's medical record was conducted. According to the physician's progress note, dated 8/14/19, Resident 9 had a surgical procedure to her left upper arm on 8/10/19.
According to the MDS assessment, dated 8/27/19, Resident 9 had an impairment to one of her upper extremities. In addition, Resident 9 required required extensive assistance with ADLs.
On 9/12/19 at 3:59 P.M., an interview with the DON was conducted. The DON stated, the type of call-button was based on the admission assessment for LROM. The DON stated, if a resident could not use the regular call-button, the nurse would determine the appropriate call-button. The DON stated all nursing staff were expected to identify the appropriate type of call-button to meet the individual needs of the residents.
A review of the facility's policy titled, Resident Call System, revised August 2019, indicated, . Return demonstration must be used when educating the resident about call light use. If the resident is unable to demonstrate appropriate call light use, the nurse must be notified to determine an adequate alternative.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
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 privacy during the delivery of care, for one (...
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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 privacy during the delivery of care, for one (29) of 26 residents reviewed for privacy.
This failure resulted in a lack of privacy when care was provided to Resident 29.
Findings:
Resident 29 was admitted to the facility on [DATE] with diagnoses which included, impaired mobility and a right below the knee amputation, per the resident's History and Physical.
On 9/9/19 at 3:24 P.M., an observation of Resident 29 was conducted in her room. Resident 29 was lying in the second bed, farthest from the door.
A review of Resident 29's medical record was conducted. Resident 29's MDS (an assessment tool), dated 6/10/19, indicated the resident required a one-person, extended assistance with bed mobility and personal hygiene. Resident 29 had a BIMS Score of 12. A BIMS Score of 8-12 indicated moderate cognitive impairment.
On 9/10/19 at 4:50 P.M., an observation of Resident 29 and CNA 22 was conducted. The door to Resident 29's room was wide open. Resident 29's privacy curtain was pulled to hide her upper body. CNA 22 was repositioning Resident 29. Resident 29's upper thigh and adult brief was visible from the door way.
On 9/10/19 at 4:55 P.M., an interview with CNA 22 was conducted. CNA 22 stated he did not have Resident 29's curtains pulled all the way during repositioning. CNA 22 further stated he should have had the curtains drawn all the way, to honor Resident 29's privacy during the delivery of care.
On 9/12/19 at 3:59 P.M., an interview with the DON was conducted. The DON stated, all nursing staff were expected to provide privacy to all residents during the delivery of patient care.
A review of the facility's policy, titled Preservation of Residents' Rights, dated May 2019, indicated, . When providing care and services, staff must respect . residents' personal privacy . during medical treatments and personal care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document a discharge status in the MDS (health status sc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document a discharge status in the MDS (health status screening and assessment tool) for one of three residents (116) reviewed for MDS coding.
This failure had the potential to result in miscommunication of the resident's discharge status.
Findings:
Resident 116 was admitted to the facility on [DATE] per the facility's admission Record.
On 9/11/19, a review of Resident 116's Progress Notes, dated 8/13/19, indicated Resident 116 was discharged home on 8/13/19.
On 9/11/19, a review of Resident 116's MDS, Section A, dated 8/13/19, indicated Resident 116's discharge status was to an acute hospital.
On 9/11/19 at 3 P.M., an interview with the MDSC was conducted. The MDSC stated Resident 116's MDS was miscoded as discharge to hospital. The MDSC stated Resident 116's MDS should have been coded as discharge to home.
On 9/12/19 at 12:08 P.M., an interview with the DON was conducted. The DON stated residents' information should be accurately documented on the MDS, because it affects the information that is given to [name of federal agency].
The facility did not have a policy related to accurate MDS documentation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide fingernail trimming in a timely manner for two...
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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 fingernail trimming in a timely manner for two of two residents (6 and 20) reviewed for ADLs.
This failure had the potential to cause skin tears and infection.
Findings:
1) Resident 6 was admitted to the facility on [DATE] with diagnoses that included functional (limited movement) quadriplegia (paralysis of all four limbs), per the facility's admission Record.
A review of Resident 6's MDS, dated [DATE], indicated, Resident 6 required extensive assistance with ADLs.
On 9/10/19 at 7:55 A.M., an observation and interview was conducted with Resident 6. Resident 6 had approximately half inch long fingernails on all four fingers and the thumb of his left hand. Resident 6 stated he would have liked to have had his finger nails trimmed.
On 9/11/19 at 10:26 A.M., an observation and interview was conducted with CNA 31. CNA 31 stated Resident 6's fingernails were too long. CNA 31 stated Resident 6's long fingernails could have scratched his skin and caused an infection.
2) Resident 20 was admitted to the facility on [DATE] with diagnoses that included generalized weakness, per the facility's admission Record.
A review of Resident 20's MDS, dated [DATE], indicated, Resident 20 required extensive assistance with ADLs.
On 9/11/19 at 11 A.M., an observation was conducted of Resident 20. Resident 20 had approximately half inch long thumb nails on both hands. On Resident 20's right hand the third and fourth finger nails were approximately quarter of an inch long. Dark matter was observed under these fingernails. On Resident 20's left hand the first and fourth finger nails were approximately half an inch long. Resident 20 was unable to verbalize.
On 9/11/19 at 11:05 A.M., an interview was conducted with CNA 32. CNA 32 stated Resident 20's finger nails were very long. CNA 32 stated Resident 20 could have scratched her skin and the long finger nails could have caused an infection.
On 9/12/19 at 4:19 P.M., an interview was conducted with the DON. The DON stated the nursing staff should have assessed all residents grooming needs. The DON stated it was a quality of life issue, especially for those residents who could not speak for themselves .
The facility's policy titled Activities of Daily Living (ADLs), dated April 2019, included . The resident will receive assistance as needed to complete activities of daily living (ADLs) . For Fingernail Care, the following procedure will be followed: 1. Ensure fingernails are clean and trimmed to avoid injury and infection .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and record the urinary output for one of four...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and record the urinary output for one of four residents (70) reviewed for catheter care.
This failure had the potential to cause Resident 70 to have a urinary output deficit.
Findings:
Resident 70 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease Stage 3 (a moderate decline in kidney function), and urinary retention (an inability to empty the bladder completely), per the facility's admission Record.
Resident 70's Care Plan, revised 8/27/19, indicated, The resident has Indwelling Catheter. at risk for UTI (urinary tract infection) . Catheter care every shift and as needed .
On 9/11/19 at 10:15 A.M., a joint interview and record review was conducted with CNA 31. CNA 31 stated all the residents who have a catheter should have a urinary output chart. CNA 31 stated there was no urinary output chart for Resident 70. CNA 31 stated Resident 70 should have had a urinary output chart to record Resident 70's daily urine output.
On 9/12/19 at 10:20 A.M., an interview was conducted with LN 33. LN 33 stated any resident with a urinary catheter required their urinary output be monitored every shift and as necessary. LN 33 stated the CNA's chart the urinary output and report the amount to the LN.
LN 33 stated it was important to know the amount of urinary output of a resident with a urinary catheter. LN 33 stated it was important to know whether a resident with a catheter was voiding urine or not, and the resident received regular catheter care.
On 9/12/19 at 4:17 P.M., an interview was conducted with the DON. The DON stated it was a concern that Resident 70's urinary output was not assessed. The DON stated it was important to assess Resident 70's urine for daily output amounts and signs of infection.
The facility's policy titled Urinary Incontinence and Indwelling Urinary Catheter (Foley) Management, dated April 2019, included, . Monitor intake and output, as ordered. Monitor for changes in urine output, including volume and color. Notify the practitioner of abnormal findings .
The facility's policy titled Monitoring Intake and Output, undated, included, . 5. Intake and output data will be documented on the I & O (intake and output) record . 6. CNA's will collect intake and output data throughout each shift and report their totals to the Nurse for each resident who is on I & O monitoring at the end of shift. 7. The Nurse will evaluate the I & O for that shift .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess the lunchtime meal intake for two 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 accurately assess the lunchtime meal intake for two of six residents (3 and 5) reviewed for nutrition.
This failure had the potential to cause the residents to become malnourished.
Findings:
1) Resident 3 was admitted to the facility on [DATE] with diagnoses that included palliative care (a shortened life expectancy of six months or less), per the facility's admission Record.
On 9/9/19 at 12:42 P.M., a dining observation was conducted in a facility dining room.
Resident 3 was seated at a dining table with three other female residents. Resident 3 fed herself lunch from a dinner plate. Resident 3's lunch consisted of cooked ham cut into bite sized pieces, mashed potatoes and steamed green beans. The serving sizes were equal sized portions each covering approximately a third of the plate. A slice of cornbread in the shape of a biscuit was served on the side in a small bowl. A small glass of orange liquid was observed to the right of the dinner plate. A small open carton of white liquid was observed next to the glass of orange liquid.
Resident 3 ate very slowly. In total Resident 3 ate three small pieces of ham and three pieces of cornbread. Resident 3 drank several times from a straw placed in the carton of white liquid. Resident 3 did not eat any of the mashed potatoes or green beans. Resident 3 drank twice from the glass of orange liquid. Then, Resident 3 began to cough into her dinner napkin, and stated I'm done.
A record review of four photos posted in the dining room titled, Meal Intake Guide, was conducted. Per review, Resident 3 ate less than 25% of the total meal.
On 9/11/19 at 4:10 P.M., an interview and record review was conducted with CNA 35. The ADL Eating Record for Resident 3, dated 9/9/19 at 12 P.M., indicated, Resident 3 consumed 51%-75% of her lunch meal. CNA 35 stated she documented Resident 3's meal intake for another CNA. CNA 35 stated she did not observe the resident's plate or meal intake. CNA 35 stated if a resident was not eating as much as was being recorded, the resident could loose weight, get weaker and possibly become sick.
2) Resident 5 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and Alzheimer's Disease (a progressive loss of mental functions), per the facility's admission Record.
On 9/9/19 at 12:42 P.M., a dining observation was conducted in a facility dining room.
Resident 5 was seated at a dining table with three other female residents. Resident 5 fed herself lunch from a dinner plate. Resident 5's lunch consisted of pureed ham, mashed potatoes and pureed green beans. Each serving size of food was approximately the size of an ice cream scoop. The food covered approximately two thirds of the plate in total. A slice of cornbread in the shape of a biscuit was served on the side, in a small bowl.
A small bowl of canned fruit, cut into small pieces, was placed to the left side of the dinner plate. Resident 5 used a spoon to feed herself three spoonfuls of food from the dinner plate, mostly consisting of the pureed ham and mashed potatoes. A small glass of orange liquid was placed to the right of the dinner plate. Resident 5 drank approximately half of the glass of orange liquid. Resident 5 did not eat any of the cornbread or the canned fruit.
A record review of four photos posted in the dining room titled, Meal Intake Guide, was conducted. Per review, Resident 5 ate less than 25% of the total meal.
On 9/12/19 at 2:44 P.M., an interview and record review was conducted with CNA 36. The ADL Eating Record at 1:17 P.M., on 9/9/19, indicated, the total amount of food Resident 5 consumed for lunch was 26%-50%. CNA 36 stated she documented Resident 5's meal intake for another CNA. CNA 36 stated she did not observe the resident's plate or meal intake. CNA 36 stated if a resident was not eating as much as was being recorded, they could become malnourished, dehydrated and have a decline in their health.
On 9/12/19 at 4:16 P.M., an interview was conducted with the DON. The DON stated accurate documentation of residents' meal intake was important. The DON stated if residents were not eating enough food, weight loss and dehydration, among other things, could occur.
The facility's policy titled Accurately Recording Food Intake in the [NAME] System, undated, included .Assessing a resident's nutritional status is very important. To successfully do so, we must have an accurate recording of intake at all meals and snacks .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the administration of a pain medication was do...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the administration of a pain medication was documented in the eMAR for one of four residents (79) reviewed for medication reconciliation.
This failure had the potential for Resident 79 to receive too much or too little pain medication.
Findings:
Resident 79 was admitted to the facility on [DATE], with diagnoses to include an open wound, per the facility's admission Record.
A review of Resident 79's medical record was conducted. There was a physician order, dated 9/3/19, for oxycodone 5 mg every four hours as needed for pain.
On 9/12/19 at 10:59 A.M., a joint record review and interview was conducted with LN 23. Resident 79 had a medication card containing 5 mg tablets of oxycodone (a controlled medication to treat pain).
According to Resident 79's CS (a log to track the number of tablets taken from the medication card), ten doses of oxycodone were signed out as taken from the medication card, from 9/4/19 to 9/11/19. Resident 79's September eMAR indicated eight doses of oxycodone were documented as being administered to Resident 79, from 9/4/19 to 9/11/19. LN 23 stated the CS and the eMAR did not match.
LN 23 stated according to the CS, on 9/5/19, a LN signed-out one 5 mg tablet of oxycodone at 4:34 P.M. and one 5 mg tablet at 9:11 P.M. LN 23 stated, the LN did not document the administration of the two tablets on the eMAR, and it should have been. LN 23 further stated, the LNs used the eMAR to determine when pain medications were given, and when the next dose could be administered.
On 9/12/19 at 3:59 P.M., an interview with the DON was conducted. The DON stated the CS and the eMAR should always match. The DON further stated LNs were expected to document medications on the eMAR when a pain medication was given.
A review of the facility's policy titled, Controlled Substances, dated November 2017, indicated, . Administer the controlled medication and document dose administration on the MAR (medication administration record) .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a dietary staff member was unable to competently test the chemical concentration of the sanitizing solution.
As a res...
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Based on observation, interview, and record review, the facility failed to ensure a dietary staff member was unable to competently test the chemical concentration of the sanitizing solution.
As a result, there was the potential for placing the residents at risk for food borne illnesses.
Findings:
On 9/9/19 at 8:18 A.M., a concurrent observation of the kitchen and an interview with the FSD was conducted. A red bucket with sanitizing solution was underneath the sink area. The FSD removed a test strip from a container and put it into the solution to test for the chemical concentration of the sanitizing solution. When compared to the test strip chart, the concentration was 10 parts per million (ppm). The FSD stated there was no numerical value needed for the concentration of the solution, as long as the color of the test strip after contact time was purple. In addition, the FSD added liquid bleach to the solution without measuring it, in an attempt to increase the concentration of the sanitizing solution.
On 9/9/19 at 4:10 P.M., an interview with RD 1 was conducted. RD 1 stated the FSD should have known the appropriate concentration of the sanitizing solution, which was 50-100 ppm.
On 9/10/19, a concurrent interview and record review with RD 1 was conducted. The facility's undated document, titled Sanitizer Use Concentrations for Food Service and Food Production Facilities, indicated, one tablespoon of liquid bleach would yield a final concentration of 50 ppm. RD 1 stated the FSD should have added one cap-full of bleach to the sanitizing solution which equaled one tablespoon.
Per the facility's policy, titled Safe Use of Chemicals, revised November 2016, Guidelines: .Chemicals used on food contact surfaces are accurately measured to avoid any toxic residue left on the surface .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was adequate staff to provide the necessary care for 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 there was adequate staff to provide the necessary care for six confidential residents (CR 1, CR 2, CR 3, CR 4, CR 5, and CR 6), and 8 of 28 residents reviewed for sufficient staffing (90, 105, 318, 321, 44, 103, 316, and 319).
This failure had the potential for residents to experience physical and emotional harm.
Findings:
A. Resident 90 was admitted to the facility on [DATE], with diagnoses which included legal blindness, per the facility's admission Record.
A review of Resident 90's medical record was conducted on 9/11/19. According to Resident 90's MDS (health status screening and assessment tool), dated 8/5/19, Resident 90 had a BIMS (an assessment tool for cognitive status) score of 15. A BIMS score of 15 indicated a person was considered cognitively intact.
On 9/9/19 at 10:21 A.M., an interview with Resident 90 was conducted. Resident 90 stated staff took a long time to answer her call light. Resident 90 stated she walked to the bathroom and pulled the call light cord because staff seemed to respond faster to the bathroom call light.
B. Resident 105 was admitted to the facility on [DATE], with diagnoses that include hemiplegia (paralysis of one side of the body) per the facility's admission Record.
On 9/11/19, a review of Resident 105's MDS, dated [DATE], indicated Resident 105's BIMS score was 15.
On 9/9/19 at 9:15 A.M., an interview with Resident 105 was conducted. Resident 105 stated the facility was understaffed and he had to wait 30-45 minutes for staff to respond to his call light. Resident 105 further stated when he had to wait a long time for his light to be answered it was un-nerving.
C. Resident 318 was admitted to the facility on [DATE] with diagnoses that include muscle weakness and low back pain, per the facility's admission Record.
On 9/12/19, a review of Resident 318's MDS, dated [DATE], indicated Resident 318's BIMS score was 15.
On 9/9/19 at 11 A.M., an interview with Resident 318 was conducted. Resident 318 stated it could take on average 30 minutes for staff to answer her call light. Resident 318 stated it was frustrating to wait that long to use the bathroom.
D. On 9/9/19 at 9:50 A.M., an interview with Resident 321 was conducted. Resident 321 stated he had been there for three days and had to wait an hour for staff to answer his call light.
On 9/9/19 at 11:26 A.M., a joint interview with Resident 44 and Resident 44's caregiver was conducted. The caregiver stated staff on average took 20-30 minutes to answer Resident 44's call light. The caregiver further stated the wait was frustrating because Resident 44 had to wait to use the bedpan (device used for toileting while in bed). Resident 44 stated she did not want to have to go to the bathroom in her brief.
On 9/9/19 at 11:51 A.M., an interview with Resident 103 was conducted. Resident 103 stated it could take staff over an hour to respond to her call light. Resident 103 stated it was difficult for her to wait that long.
On 9/9/19 at 12 P.M., an interview with Resident 316 was conducted. Resident 316 stated she had a hard time getting help because she had to wait a long time for her call light to be answered and felt helpless. Resident 316 stated to get her call light answered faster, her roommate would also turn on her call light.
On 9/9/19 at 3 P.M., an interview with Resident 319's family member was conducted. The family member stated Resident 319 had to wait 20 minutes for her call light to be answered, and caused Resident 319 to wait too long to get her brief changed.
E. In a confidential interview with CR 1, CR 1 stated his call light, on average, could take 30-45 minutes for it to be answered.
On 9/9/19 at 10:15 A.M., an interview with CR 2 was conducted. CR 2 stated staff could take 20-30 minutes or longer to answer his call light. CR 2 stated it was frustrating to wait that long, because it could be an emergency when he turned on his call light and staff would not get to him in time.
In a joint confidential interview with CR 3 and CR 4, CR 4 stated she had to wait more than 30 minutes for her call light to be answered at times, and it was too long for her to wait. CR 3 stated she also had to wait too long for her call light to be answered.
In a confidential interview with CR 5, CR 5 stated one day she had to wait in the bathroom for 45 minutes for someone to answer her call light. CR 5 stated she was sitting on a commode (a movable toilet), which was hard and could cut into her skin. CR 5 stated it felt bad to wait for her call light to be answered.
In a confidential interview with CR 6, CR 6 stated it was an awful lot of time from pressing the call button to the staff's response. CR 6 stated she timed the staff's response with her watch, and it was 20 minutes. CR 6 further stated she felt frustrated and wished staff would come sooner. CR 6 further stated she had discussed this issue with resident council (an organization of people living together) and to administration, but had not seen a change.
On 9/11/19 at 9:28 A.M., an interview with CNA 12 was conducted. CNA 12 stated call lights should be answered right away and take no more than 10 minutes to answer. CNA 12 further stated all staff should answer the call light.
On 9/12/19 at 7:05 A.M., an interview with CNA 21 was conducted. CNA 21 stated, when the call light cord in the bathroom was activated, the call light above the door flashed, and a different sound alarmed, which indicated an urgency. CNA 21 stated it was expected for nursing staff to respond to the bathroom call light immediately, because it was a priority.
On 9/11/19 at 9:32 A.M., an interview with LN 11 was conducted. LN 11 stated all staff should answer call lights right way.
On 9/12/19 at 12:08 P.M., a joint interview with the DON and the ADM was conducted. The DON stated all staff should answer call lights as soon as possible, because it could be an emergency, and for the safety of the residents. The ADM stated staff call lights were urgent and should be responded to quickly.
According to the facility's policy, Resident Call System, Revised April 2016, .1. All facility associates must be aware of call lights at all times. 2. All associates must answer call lights whether or not they are assigned to provide care to that resident .
According to the facility's policy, Staffing, Effective Date April 2019, .The facility maintains adequate staff on each shift to meet residents' needs .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the lunch menu for one of six residents review...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the lunch menu for one of six residents reviewed for food (318).
This failure had the potential for Resident 318's nutritional status to go unmet.
Findings:
Resident 318 was admitted to the facility on [DATE], per the facility's admission Record.
On 9/12/19, a review of Resident 318's MDS assessment, dated 9/11/19, indicated Resident 318 had a BIMS score of 15. A BIMS score of 15 indicated cognition was intact.
On 9/9/19 at 11 A.M., an interview with Resident 318 was conducted. Resident 318 stated she was on a special heart diet while she was at the facility, and received the same meal everyday pretty much. Resident 318 stated she received chicken and rice frequently, and it was depressing eating the same meal every day.
On 9/10/19, a review of Resident 318's physician orders were conducted. An order dated 9/4/19 indicated Resident 318 was on a low sodium diet.
On 9/9/19 at 12 P.M., an observation and interview with Resident 318 was conducted. Resident 318's lunch consisted of chicken, rice, green beans, and fruit. Resident 318 stated this was the same chicken and rice meal she frequently received.
On 9/11/19 at 2:28 P.M., a joint interview and record review with RD 1, RD 2, and the FSD was conducted. RD 1 stated Resident 318 had an order for a low-sodium diet. RD 2 reviewed the menu spreadsheet for the week and stated the low-sodium lunch menu for 9/9/19 consisted of salt free baked pork chop, half a baked sweet potato, salt free green beans, and fruit. The FSD stated staff should follow the spreadsheet when making meals and did not know why Resident 318 received chicken instead of a pork chop on 9/9/19.
On 9/11/19 at 3:10 P.M., a joint interview and record review with RD 2 and the FSD was conducted. The FSD reviewed Resident 318's food preferences and stated Resident 318 did not have any preferences for certain foods. The FSD further stated Resident 318 received rice instead of a sweet potato on 9/9/19 because the facility ran out of sweet potatoes. RD 2 stated it sounds like she got into a cycle of chicken and rice and RD 2 did not know why the resident received chicken instead of a pork chop. RD 2 further stated the menu spreadsheet should have been followed residents so residents could have the best nutritional status while they are at the facility.
On 9/11/19 at 4 P.M., an interview with RD 1 was conducted. RD 1 stated Resident 318 should have received regular potatoes on 9/9/19 when the facility ran out of sweet potatoes and did not know why Resident 318 received rice.
According to the facility's policy, titled Diet Spreadsheets, dated December 2012, . 1 .Diet spreadsheets must reflect the menu exactly as it is served/portion sizes and special notations .
According to the facility's policy, titled Food Preferences, dated January 2010, .Residents rely on Dining Services for their complete nutrition in meals .
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
- • No fines on record. Clean compliance history, better than most California facilities.
- • 35% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s). Review inspection reports carefully.
- • 47 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade F (30/100). 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 Vista View Post Acute's CMS Rating?
CMS assigns VISTA VIEW POST ACUTE 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 Vista View Post Acute Staffed?
CMS rates VISTA VIEW POST ACUTE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 35%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Vista View Post Acute?
State health inspectors documented 47 deficiencies at VISTA VIEW POST ACUTE during 2019 to 2025. These included: 1 that caused actual resident harm, 45 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Vista View Post Acute?
VISTA VIEW POST ACUTE 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 DAVID & FRANK JOHNSON, a chain that manages multiple nursing homes. With 176 certified beds and approximately 132 residents (about 75% occupancy), it is a mid-sized facility located in VISTA, California.
How Does Vista View Post Acute Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, VISTA VIEW POST ACUTE's overall rating (2 stars) is below the state average of 3.1, staff turnover (35%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Vista View Post Acute?
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 Vista View Post Acute Safe?
Based on CMS inspection data, VISTA VIEW POST ACUTE 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 Vista View Post Acute Stick Around?
VISTA VIEW POST ACUTE has a staff turnover rate of 35%, 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 Vista View Post Acute Ever Fined?
VISTA VIEW POST ACUTE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Vista View Post Acute on Any Federal Watch List?
VISTA VIEW POST ACUTE 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.