UNIVERSITY HEIGHTS CARE CENTER
For profit - Limited Liability company
105 Beds
VIVAGE SENIOR LIVING
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
21/100
#173 of 208 in CO
Photo by University Heights
Photo by University Heights
Photo by University Heights
1 / 5 photos
Last Inspection: January 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
University Heights Care Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #173 out of 208 facilities in Colorado, placing it in the bottom half, and #19 out of 20 in Arapahoe County, meaning there is only one local option that is rated worse. While the facility's trend is improving, having reduced issues from 18 in 2024 to 3 in 2025, it still reported a total of 40 deficiencies, including critical failures to protect residents from abuse and neglect. Staffing is a relative strength, with a 4/5 star rating and a turnover rate of 36%, which is better than the state average, while RN coverage is average. However, there are serious concerns, including incidents where a resident with cognitive impairment was left unsupervised during a medical appointment and another resident developed multiple severe pressure ulcers due to inadequate care and nutritional support.
- Trust Score
- F
- In Colorado
- #173/208
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 36% turnover. Near Colorado's 48% average. Typical for the industry.
- Penalties ○ Average
- $9,315 in fines. Higher than 66% of Colorado facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 41 minutes of Registered Nurse (RN) attention daily — about average for Colorado. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
21/100
Bottom 17%
Review needed
18 → 3 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 18 issues
2025: 3 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (36%)
12 points below Colorado average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Colorado average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 36%
Near Colorado avg (46%)
Typical for the industry
Federal Fines: $9,315
Below median ($33,413)
Minor penalties assessed
Chain: VIVAGE SENIOR LIVING
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 40 deficiencies on record
1 life-threatening 3 actual harm
Mar 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents reviewed for accidents out of 12 sample residents.
Specifically, the facility failed to:
-Ensure Resident #4 was provided with the supervision necessary to prevent elopement; and,
-Ensure Resident #4's elopement on 3/2/25 was investigated thoroughly.
Findings include:
I. Facility policy and procedure
The Elopement and Wandering policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/26/25 at 3:36 p.m. It read in pertinent part, It is a goal of the facility to provide a safe environment using the least restrictive measures available in care for residents who are exhibiting elopement behavior.
'Elopers' are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks.
II. Resident #4
A. Resident status
Resident #4, age less than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included dementia and schizophrenia.
The 3/12/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He was independent with most activities of daily living (ADL) but required supervision/touching assistance with showering.
According to the assessment, Resident #4 had a wander/elopement alarm.
B. Record review
The elopement care plan, revised 3/17/25, documented Resident #4 was an elopement risk. He was unsafe to be in the community independently related to an unsteady gait and history of falling when ambulating to the gas station. The resident had a wander guard in place and his picture and information was in the facility's wander/elopement binder.
Resident #4 liked to sit on the couch in the common area at times. Resident #4 would attempt at times to remove his wander guard and would ask staff to remove it. Interventions included ensuring the resident's current identification form was in the elopement binder, reassuring the resident that he had enough cigarettes and that he did not have to buy any at that time had been a successful intervention in the past with redirecting exit seeking behaviors, the resident liked to drink Mountain Dew and eat Lay's potato chips, offering these snacks may also assist in redirecting him, identifying patterns of wandering, intervening as appropriate, distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books, providing structured activities, such as toileting, walking inside and outside, reorientation strategies including signs, pictures, calling his sister, a wander guard for safety and checking placement of the device, which was located on the resident's right wrist every shift.
The 9/13/24 physical restraint/safety device informed consent form for a wander guard due to safety reasons to prevent Resident #4 from going out of the facility unassisted documented Resident #4 gave verbal consent to have a wander guard placed.
The wander/elopement risk evaluation, dated 3/10/25, documented Resident #4 routinely wandered or paced and had previous attempts to elope at the facility.
Review of Resident #4's electronic medical record (EMR) revealed the following progress notes:
The nursing progress note, dated 3/2/25 at 7:22 a.m., documented Resident #4 left the facility at about 5:30 a.m. through the back door of the smoking area. The nurse and a certified nurse aide (CNA) went outside to look for the resident around the block but did not find him. The nurse called the on-call nurse who then notified the NHA and the director of nursing (DON) about the situation. The NHA told the nurse to call 911 and report that Resident #4 was missing. The on-call nurse practitioner was notified, and a message was left for the resident's emergency contact. A couple of police officers came to the facility at about 7:15 a.m. and asked the nurse questions about the resident. The police said they were going to look at the cameras and try to find the resident.
The nursing progress note, dated 3/2/25 at 1:33 p.m, documented Resident #4 was reported to have left the facility at 5:30 a.m., according to the night nurse. The nurse spoke to the local police department about Resident #4's contacts, where he could be going and was able to provide a photo of the resident. Resident #4 returned to the facility about 11:30 a.m. Resident #4's vital signs were taken upon his return to the facility and he was assessed to have no new skin wounds or contusions. The police officers followed up around 2:15 p.m. and spoke to the resident. Resident #4 said he wanted to open a bank account and get a bank card. He said he left the facility to go to the bank but the bank was closed. The nurse informed Resident #4 that staff could help facilitate him opening a bank account.
The facility's investigation report for Resident #4's 3/2/25 elopement incident was requested from the NHA on 3/26/25 at 11:40 a.m.
-On 3/26/25 at 1:40 p.m. the NHA said the facility did not have an investigation report for the 3/2/25 elopement incident and the elopement was not reported to the State Agency.
III. Staff interviews
CNA #1 was interviewed on 3/25/25 at 4:39 p.m. CNA #1 said Resident #4 was a smoker and went outside to smoke during smoking times. CNA #1 said Resident #4 was a supervised smoker. She said staff had to be outside with Resident #4 and watch him while he smoked. She said Resident #4 only liked to go outside to smoke but would not sit outside and hang out.
CNA #1 said Resident #4 had a wander guard on for his safety and because he liked to elope. CNA #1 said she did not know if Resident #4 had eloped from the facility. CNA #1 said the facility had a smoking schedule and had to remind Resident #4 of the times. She said Resident #4 was able to go outside when he wanted. She said the wander guard alarmed when he exited the door to go outside. She said the resident did not stay outside and would come back inside right after he was done smoking.
Registered nurse (RN) #1 was interviewed on 3/25/25 at 4:17 p.m. RN #1 said Resident #4 was fairly independent. RN #1 said Resident #4 got up pretty early and would be up by 5:00 a.m. RN #1 said Resident #4 stayed in his room and only came out to smoke. RN #1 said Resident #4 was a supervised smoker. RN #1 said the facility had smoking times and when it was time to go out to smoke, a CNAwent outside with the residents. She said the CNA was outside the whole time the residents were outside smoking. She said Resident #4 did not like to hang out outside and usually came back inside when he was done smoking. She said Resident #4's biggest behaviors were around him being able to smoke. She said Resident #4 had done better with knowing the smoking times. She said Resident #4 was developing a routine.
RN #1 said Resident #4 had a wander guard on for his safety and elopement reasons. RN #1 said Resident #4 had had a couple of attempts of leaving the facility. RN #1 said there were alarms on the outside gates and if Resident #4 tried to leave, the alarm would go off.
RN #1 said Resident #4 had not tried to elope while he was outside smoking. RN #1 said Resident #4 had eloped during other times of the day. RN #1 said Resident #4 was fixated on going to the bank and getting more cigarettes. She said Resident #4 was confused about the time of day.
The NHA, the DON, the social services director (SSD), and the clinical consultant (CC) were interviewed together on 3/26/25 at 1:40 p.m. The NHA said Resident #4 had eloped and went to the bank on 3/2/25. The NHA said Resident #4 was focused on going to the bank and getting cigarettes. He said Resident #4's cigarettes were provided to him by the facility. He said Resident #4 had exited through the back door and then through the wood fence.
The NHA said Resident #4 had a wander guard. The NHA said he did not know how long the resident had had the wander guard. The NHA said Resident #4 had a wander guard because staff did not know Resident #4's baseline. He said Resident #4 was a high elopement risk.
The DON said Resident #4 did not have cigarettes. The DON said Resident #4's family was not willing to provide the cigarettes for him. The DON said the facility bought packs of the cigarettes for Resident #4 but it got expensive. She said they bought tobacco and started rolling his cigarettes. The DON said during the weekends, Resident #4 was afraid that he was going to run out of cigarettes. She said that was one of the resident's biggest fears.
The DON said activities thought about putting Resident #4 on a work program to keep him busy. The DON said she spoke to activities but they did not offer Resident #4 a work program.
The DON said on 3/2/25 Resident #4 eloped from the back gate. The DON said staff noticed the alarm was going off. The DON said she did not know if staff just turned off the alarm and did not know Resident #4 had left. She said she could not speak to what occurred that day. The DON said when the alarms sound, staff are supposed to look for whichever resident set the alarm off. She said that morning (3/2/25), it was dark outside. She said Resident #4 was fast and staff were not able to see where he had gone. The DON said staff called the NHA and let him know what was going on. The DON said staff searched the block and could not find the resident, so they called 911. The DON said Resident #4 came back to the facility on his own.
The DON said she could not speak on behalf of the staff who were working that morning as to whether they responded to the alarm quickly or not. She said she could not speak to what a reasonable amount of time staff should have before they turn the alarm off. She said she did not know what staff were doing at the time the alarm went off. She said the response time for the alarms should be less than five minutes.
The NHA said the back gate had a different alarm on it. The NHA said staff should know the difference between the door alarm and the gate alarm. The NHA said there was a key by the nurses station and staff had to go to the fence alarm to turn it off with the key.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#2) of five residents out of 13 sample r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#2) of five residents out of 13 sample residents who were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being.
Specifically, the facility staff failed to implement person-centered interventions to prevent Resident #2 from displaying physically aggressive behaviors toward other residents related to her diagnosis of dementia.
Findings include:
I. Facility policy and procedure
The Dementia-Clinical Protocol policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/27/25 at 2:30 p.m. It revealed in pertinent part, The staff will review the current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual's condition, related complications, and functional abilities and impairments.
The IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. Nursing assistants will receive initial training in the care of residents with dementia and related behaviors.
The facility will strive to optimize familiarity through consistent staff-resident assignments. Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise.
Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools). Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT.
II. Resident #2
A. Resident status
Resident #2, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 computerized physician orders (CPO), the diagnoses included schizoaffective disorder (depressive type- mental disorder), anxiety disorder and Alzheimer's disease.
The 1/21/25 minimum data set (MDS) assessment revealed Resident #2 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. She required the assistance of one person with transfers, dressing, showering, toileting and personal hygiene.
The MDS assessment documented Resident #2 had physical behavioral symptoms directed toward others which occurred every one to three days during the assessment period.
A. Observations
During continuous observation on 3/25/25, beginning 9:25 a.m. and ending at 5:00 p.m. the following was observed:
At 9:25 a.m. Resident #2 was in her room.
At 1:15 p.m. Resident #2 exited her room and began self-propelling herself down the hallway. Staff members were at the nursing station did not follow Resident #2 while she was wheeling herself down the hallway on her way to the facility's candy store and then returned to her room. She passed close to two residents and interacted with one staff member.
At 3:10 p.m. Resident #2 exited her bedroom, self propelled herself down the hallway toward the dining room and stayed there until it was dinner time. She passed by residents in the hallway. Staff did not step in between Resident #2 and other residents as they were passing.
During continuous observation on 3/26/25, beginning 8:45 a.m. and ended at 12:00 p.m., the following was observed:
At 8:45 a.m. Resident #2 was in the physical therapy gym.
At 9:00 a.m. Resident #2 self propelled herself out of the physical therapy gym and went to her bedroom. She passed close to other residents and staff members while wheeling herself down the hallway to her room. Staff members did not step in between Resident #2 and any other resident she passed by in the hallway.
At 10:20 a.m. Resident #2 self propelled herself from her room to the management offices and then to the dining room without supervision. She passed close by other residents and staff members while she wheeled through the hallway. Staff members did not step in between Resident #2 and any other resident she passed by in the hallway.
B. Record review
The behavioral care plan, initiated on 12/24/19 and revised on 1/21/25, documented Resident #2 had targeted behaviors of paranoia and could have a short temper. The care plan documented when cycling, she would make false accusations, believing staff were talking about her and making fun of her. Resident #2 hit people in the past due to being short tempered and impulsive responses. The interventions included one-to-one conversations with staff to discuss her feelings, assisting the resident out of the middle of the hallway, encouraging her to travel on one side of the hallway to mitigate disruptive interactions with others, assigning a one to one caregiver for emotional support, speaking to the resident calmly, educating the resident to stay away from people she does not get along with and administering and monitoring medications as ordered.
-However, observations revealed Resident #2 was not encouraged to travel on one side of the hallway as indicated on her care plan (see observations above).
The 11/6/24 nursing progress note documented Resident #2 continued to have irritability towards other residents at times in the hallways and would become verbally aggressive when provoked.
The 11/24/24 nursing progress note documented Resident #2 grabbed another resident's hair after contact between wheelchairs in the hallway.
The 1/2/25 progress note documented Resident #2 was in the hallway self-propelling her wheelchair. Resident #13 was waiting for Resident #2 to pass when Resident #2 hit him in the middle of his chest. An assessment was completed and with no injury noted. Both residents were placed on frequent safety checks.
The 1/2/25 incident report documented when Resident #2 was next to Resident #13 in the hallway, she stopped and hit him for no reason. Resident #2 said, stating get out my way. Resident #13 said he put his hand on Resident #2's head to stop her and said, stating What the hell old lady. Resident #2 said she was trying to stop Resident #13 from bumping into her.
The 2/3/25 nursing progress note documented Resident #2 tried to hit and scratch the nurse when he asked how he could help Resident #2.
The 2/26/25 incident report documented Resident #1 was passing in the hallway when Resident #2 was self-propelling her wheelchair in the opposite direction. Resident # 1 stopped and stood to the side so that Resident #2 could pass him. When Resident #2 passed by Resident #1 him, she slapped him on his left cheek with her open hand. The incident was witnessed by a dietary aide.
Cross reference F600: the facility failed to prevent physical abuse by Resident #2 toward other residents.
III. Staff interviews
Certified nurse aide (CNA) #3 was interviewed on 3/25/25 at 5:10 p.m. CNA #3 said Resident #2 yelled, screamed, and tried to scratch other residents and staff members often. She said she would give Resident #2 space when she was having a bad day. CNA #3 said every time Resident #2 had a bad day, the facility staff did not walk with the resident down the hallway. She said it was easier to give her space so they did not get hit or scratched. She said she did not try to walk between Resident #2 and any other residents coming down the hallway to ensure another resident was not targeted by Resident #2. She said was concerned if she was too close to Resident #2 during those episodes, she would get hit or scratched.
CNA #3 said Resident #2 did not always like it when other residents invaded her personal space and got too close. She said Resident #2 could become physically aggressive if that happened.
CNA #4 was interviewed on 3/26/25 at 10:00 a.m. CNA #4 stated that Resident #2 gets frustrated when she could not move. CNA #4 said that changed her mood and the behaviors began.
CNA #4 said when incidents happened, the staff usually addressed the cause of the issue and gave her some space. CNA #4 said in order to protect other residents during these incidents, the staff separated them and took Resident #2 to her bedroom.
Registered nurse (RN) #3 was interviewed on 3/25/25 at 5:25 p.m. RN #3 said the facility staff gave Resident #2 space and would backup away from her when she was upset. She said Resident #2 was physically aggressive when she was having a bad day. She said Resident #2 could be physically aggressive with facility staff or toward other residents. She said she was concerned if she got too close to Resident #2 during a bad day she would be hit.
RN #3 said the facility staff did not provide Resident #2 with one-to-one supervisor when she moved about the facility. She said facility staff did not walk down the hallway to follow the resident and stand between Resident #2 and another resident coming down the hallway if Resident #2 was having a bad day. She said Resident #2 did not like other residents getting too close to her.
RN #3 said if Resident #2 was physically aggressive with another resident, she would be placed on 15-minute safety checks for three days.
The director of nursing (DON), the NHA, the clinical consultant (CC) and the regional operations manager (ROM) were interviewed together on 3/26/25 at 1:36 p.m. The DON said Resident #2 had a history of physically aggressive behavior toward other residents and staff members. The DON said she had been institutionalized at a young age and had a difficult time trusting others. She said Resident #2 was very protective of her belongings and personal space. The DON said Resident #2 does the best when she is regimented in a daily routine.
The DON said Resident #2 was triggered by what she perceived as another resident getting too close to her, especially in areas such as the hallway. She said the resident had a large personal bubble that was not always obvious to others and was paranoid about people whispering or talking about her behind her back.
The NHA said there were a few staff she trusted and had built a good relationship. He said she was part of a program through her insurance that will provide a one-to-one companion once or twice a week for one to two hours.
The DON said if Resident #2 was having a bad day, the floor staff should notify management and someone she trusted and had a good rapport with would go down and sit with her. She said staff should keep an eye on Resident #2 when she left her room often, because that could be a sign of a bad day. She said the floor staff should walk down the hallway in between Resident #2 and another resident to ensure the other resident does not get too close to Resident #2 to prevent an altercation.
The NHA said the facility staff should be aware of Resident #2's triggers and the interventions identified on the care plan.
The DON said staff should be walking in between Resident #2 while she wheeled herself down the hallway to ensure she does not have a physically aggressive incident with another resident.
The NHA confirmed the interventions identified on the comprehensive care plan could not be evaluated to be effective or ineffective without implementation by all staff.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Incident of physical abuse by Resident #7 towards Resident #6 on 2/12/25
A. Facility investigation
The 2/12/25 facility inc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Incident of physical abuse by Resident #7 towards Resident #6 on 2/12/25
A. Facility investigation
The 2/12/25 facility incident report was provided by the NHA on 3/26/25 at 10:30 a.m.
The report revealed Resident #7 came into the dining room and yelled at Resident #6. Resident #6 began yelling back at Resident #7. Resident #7 hit and pushed Resident #6's head causing him to tip over backwards in his wheelchair. The residents were immediately separated, placed on frequent checks and assessed. Resident #6 was assessed by the DON and no injuries were noted.
Resident #6 was interviewed by the facility on 2/12/25 and said that crazy (explicit word) just came over and hit me. I was just sitting here and she came and knocked me over. When asked if he was hurt or if he was afraid he stated, No, I' m not hurt and I am not afraid of that crazy (explicit word), she is just mental.
Resident #7 was interviewed by the facility on 2/12/25. Resident #7 stated, I just came to the dining room to ask for something and he came up behind me and when I turned around he hit me, so I hit him back defending myself. He has a loud mouth and everyone is tired of hearing it.
The cook (CK) was interviewed by the facility on 2/12/25. The CK said Resident #6 went to the kitchen window and asked the staff for salsa. Resident #7 approached the window and began arguing with him. Resident #7 hit Resident #6 and his wheelchair fell and knocked Resident #7 on the ground. The CK said staff stood between the residents and called for assistance.
A dietary aide DA was interviewed by the facility on 2/13/25. The DA said Resident #6 went to the kitchen window and asked the staff for salsa. Resident #7 approached the window and began arguing with him. Resident #7 hit Resident #6 and his wheelchair fell and knocked Resident #7 on the ground. The staff stood between residents and called for assistance.
The conclusion of the investigation revealed Resident #7 was educated to avoid interactions with those that annoy her. The incident report was substantiated as it was witnessed by staff.
B. Resident #7 - assailant
1. Resident status
Resident #7, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included mood disorder and dementia.
The 2/5/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 11 out of 15. She was independent with all activities of daily living (ADLs).
The assessment indicated Resident #7 did not exhibit any physical or verbal behavioral symptoms directed towards others.
2. Record review
The behavior care plan, revised 2/28/25, documented Resident #7 had the potential to be physically aggressive with other residents related to anger and anxiety, dementia processes related to traumatic brain injury (TBI), history of harm to others, poor impulse control and low frustration tolerance related to her TBI. Pertinent interventions included:
-Analyzing times of day, places, circumstances, triggers, and what de-escalates behavior;
-Providing physical and verbal cues to alleviate anxiety;
-Encouraging the resident to seek out of staff members when agitated;
-Encouraging the resident to share her frustrations about other residents to staff members;
-If agitated, providing the resident with a safe, quiet place to discuss her feelings openly;
-Modifying the environment by reducing noise, dimming the lights and keeping the door closed;
-Encouraging the resident to eat in another area if she was upset;
-Monitoring observed behavior and attempted interventions in behavior log every shift;
-Monitoring/documenting/reporting as needed any signs or symptoms of resident posing danger to self and others; and,
-Offering the resident assistance with calling her son when she was having periods of frustration.
The cognition care plan, revised 9/18/23, documented Resident #7 had impaired cognitive function/dementia or impaired thought processes related to status post head injury and bipolar disorder. Pertinent interventions included asking yes/no questions in order to determine the resident's needs, identifying self at each interaction, facing the resident when speaking and making eye contact and providing the resident with necessary cues.
The nursing progress note, dated 2/12/25, documented that at approximately 9:10 a.m. Resident #7 was screaming very loudly towards Resident #6 at the corner of the dining room. Resident #7 was on the floor in a sitting position. Resident #7 said while she was walking, Resident #6 started cursing her out, so she stopped and said do not curse me out. Resident #7 said right after she told Resident #6 to stop cursing, he pushed her to the floor. Resident #7 said they were friends and she would ask Resident #6 for an apology. A head to toe assessment was completed and no injury was noted.
The behavior note, dated 2/13/25, documented Resident #7 was involved in a reportable physical resident-to-resident altercation with no injury noted on 2/12/25. Resident #7 initiated the physical aggression and upon interview stated it was Resident #6 who initiated the aggression. Resident #7 said she had no fear of Resident #6 or any other person at the facility.
C. Resident #6 - victim
1. Resident status
Resident #6, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included spina bifida (a condition that occurs when the spine and spinal cord do not form properly) and Wernicke's encephalopathy (a degenerative brain disorder caused by a lack of vitamin B1).
The 2/6/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 12 out of 15. He required partial and moderate assistance with showering and personal hygiene.
According to the MDS assessment the resident had verbal behavioral symptoms directed toward others that occurred on one to three days during the assessment review period.
2. Resident interview
Resident #6 was interviewed on 3/26/25 at 11:56 a.m. Resident #6 said he could not recall the incident with Resident #7 on 2/12/25. Resident #6 said if someone pushed him he would not be happy and he would want to get that person out of the facility. He said if a resident was really aggressive and pushed him, he would be afraid. He said he would not be happy at all. Resident #6 said he did not have any problems with staff or residents. He said he did not feel threatened by anyone and felt safe at the facility.
3. Record review
The behavior care plan, revised 3/9/24, documented due to his diagnosis of Wernicke's encephalopathy, Resident #6 had frequent outbursts of cursing, sometimes the outbursts had a direct cause, other times they did not. Pertinent interventions included:
-Anticipating and meeting the residents' needs;
-Assisting the resident to develop more appropriate methods of coping and interacting by having him remove himself from the situation when he became frustrated and working on calming himself down;
-Encouraging the resident to express his feelings appropriately;
-Providing an opportunity for positive interaction and attention; and,
-Discussing the resident's behavior, explaining why his behavior was inappropriate and/or unacceptable and how there were better ways to discuss his frustrations.
The cognition care plan, revised 7/19/23, documented Resident #6 had impaired cognitive function related to TBI. Pertinent interventions included communicating with the resident/family/caregivers regarding the resident's capabilities and needs, using the resident's preferred name, identifying self at each interaction and facing the resident when speaking and making eye contact.
The progress note, dated 2/12/25, documented Resident #6 was angry and speaking very loudly towards another resident at the corner of the dining room. Upon arrival the nurse observed Resident #6 on the floor in a sitting position beside his wheelchair. Resident #6 did not say anything about how he ended up on the floor. A head to toe assessment was completed and the resident was alert and oriented times two to three with periods of confusion and forgetfulness. The note documented the resident did not have a mental status change. Resident #6 denied hitting his head and there was no bump or skin issue observed. The resident's vital signs were within normal limits. Resident #6 was assisted off the floor and was sitting in his wheelchair. Neurological follow up was initiated. The physician and the DON were notified.
The progress note, dated 2/12/25, documented at 9:10 a.m. Resident #6 was angry and screaming very loudly towards another resident at the corner of the dining room. Resident #6 was on the floor in a sitting position besides his wheelchair. Resident #6 was wheeled back to his room. Resident #6 apologized to Resident #7.
4. Staff interviews
CNA #2 was interviewed on 3/26/25 at 9:51 a.m. CNA #2 said Resident #7 was friendly with staff and residents. She said Resident #7 would notify staff if a resident was hollering and would intervene and tell the resident to stop hollering.
CNA #2 said she had not seen Resident #7 become aggressive with staff or residents. CNA #2 said she was working the day of the physical altercation on 2/12/25. She said she was not in the dining room when the incident happened. She said she heard about the incident. She said that Resident #7 and Resident #6 had never had any history of verbal or physical aggression towards each other.
CNA #2 said the DON and the supervisor told her to keep an eye on both residents and if she saw something to report it right away to the nurse.
CNA #2 said Resident #6 used his call light frequently and if no one answered he would come out of his room and shout. CNA #2 said he would yell for help, saying he needed a nurse, needed coffee or needed his bed made. CNA #2 said Resident #6 cursed a lot. CNA #2 said when Resident #6 did not get attention right away he would get upset. CNA #2 said when staff saw Resident #6 out of his room they would go over and talk to him. She said when she passed the resident's room that she checked in on him all the time.
RN #2 was interviewed on 3/26/25 at 10:17 a.m. RN #2 said Resident #7 had never had any aggressive behaviors. RN #2 said that Resident #7 would get upset, but not to the point of hitting anyone.
RN #2 said she was working the day of the 2/12/25 incident. RN #2 said she was in the break room and was coming out and she heard screaming. RN #2 said the kitchen staff told her to come to the dining room. RN #2 said Resident #7 was on the floor and was calm. She said Resident #6 was cursing at Resident #7. She said she took vital signs on both residents. RN #2 said Resident #7 said when she was walking by Resident #6 he pushed her. Resident #6 said Resident #7 was combative towards him. She said she did not know what exactly happened as she responded after the incident happened. She said both residents were safe. She said she assisted Resident #6 in his wheelchair back to his room. She said Resident #6 had apologized for his behavior.
RN #2 said both residents had never had any issues with each other. RN #2 said both residents were friendly with each other and had not had any other issues.
RN #2 said Resident #6 was easily redirected with his behaviors. RN #2 said if his needs were not met right away he would start yelling. RN #2 said he got upset and frustrated with being in a wheelchair and being in a nursing facility.
RN #2 said Resident #6 was not a difficult person to work with but he would repeatedly ask the same question over and over again.
RN #2 said she was not aware of Resident #6 having any incidents of being verbally or physically aggressive towards staff or residents.
The social services director (SSD) was interviewed on 3/26/25 at 12:34 p.m. The SSD said Resident #7 had a history of being verbally aggressive. The SSD said Resident #7 intervened with other residents about their eating habits. She said Resident #7 had a history of making false accusations and being sexually inappropriate.
The SSD said she watched the video of the incident on 2/12/25. The SSD said the video showed Resident #7 going in the dining room and yelling at Resident #6. The SSD said witnesses said they heard Resident #7 telling Resident #6 to stop yelling. She said Resident #7 had hit Resident #6 in the face/neck area with an open hand. She said Resident #7 hit Resident #6 and he fell backwards in his wheelchair. She said Resident #7 was the aggressor as she approached Resident #6. She said Resident #6's wheelchair hit Resident #7 which made her fall to the ground. She said staff acted right away and separated the two residents and both residents were assessed.
The SSD said she was not aware of the two residents having any issues with each other in the past. The SSD said currently the two residents were cordial with each other. She said she did not think they remembered what happened. She said she was surprised that Resident #7 was the aggressor.
The SSD said Resident #6 was very friendly and easy going. The SSD said if Resident #6 did not get something immediately he would yell and curse. She said Resident #6 cursed a lot. She said when the resident felt like he was getting upset he would ask for one-to-one conversations and go to his room. She said Resident #6 liked to go outside and get fresh air. She said those interventions seemed to be successful for the resident.
The SSD said Resident #6 had never been physically aggressive towards other residents.
The DON was interviewed on 3/26/25 at 2:43 p.m. The DON said Resident #7 had a TBI and had impulse control issues.
The DON said Resident #6 was in the kitchen by the window and Resident #7 came up the hall and was talking with her hands. The DON said both residents were talking and Resident #7 reached out with an open hand and smacked Resident #6. She said when Resident #6 was trying to get away from Resident #7, he caught Resident #7's leg and she also fell. She said Resident #6 was trying to get away from Resident #7 and he fell to the side of his wheelchair. She said the residents did not sustain any injuries. She said Resident #6 did not have redness from where Resident #7 made contact.
The DON said Resident #7 had hit Resident #6 because she was frustrated because he was yelling explicit language.
The DON said Resident #7's solution was to hit Resident #6.
The DON said both residents were monitored for three days. The DON said the staff charted resident behaviors by exception and if they noticed an issue.
The DON said that both residents had not had any other issues. She said both residents got along well with each other.
The DON said Resident #6 had low frustration tolerance and when he did not get the answer he wanted, he would start yelling and cursing.
Based on record review and interviews, the facility failed to ensure three (#13, #1 and #6) of five residents out of 13 sample residents were kept free from abuse.
Specifically, the facility failed to:
-Ensure Resident #13 and Resident #1 were kept free from physical abuse by Resident #2; and,
-Ensure Resident #6 was kept free from physical abuse by Resident #7.
Findings include:
I. Facility policy and procedure
The Abuse policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/27/25 at 2:30 p.m. It revealed in pertinent part, Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs.
The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms.
II. Incident of physical abuse by Resident #2 towards Resident #1 and Resident #13
A. Facility investigation of physical abuse by Resident #2 towards Resident #13 on 1/2/25
The 1/2/25 incident report documented Resident #13 was walking next to Resident #2 in the hallway when Resident #2 stopped and hit Resident #13 for no reason. Resident #13 put his hand on her head to stop her. After the incident, Resident #13 stated I was not afraid of her hitting me again; it is not a big deal; she is just a confused, mean old lady.
The incident report documented the incident was witnessed by the admissions coordinator. The witness statement and interviews substantiated the physical abuse by Resident #2 toward Resident #13.
The facility called the police and notified the ombudsman, the director of nursing (DON), the attending physician and the state health department.
B. Facility investigation of physical abuse by Resident #2 towards Resident #1 on 2/26/25
The 2/26/25 incident report documented Resident #1 was passing in the hallway when Resident #2 was self-propelling her wheelchair in the opposite direction. Resident # 1 stopped and stood to the side so that Resident #2 could pass by him. When Resident #2 passed by Resident #1, she slapped Resident #1 on his left cheek with her open hand. Resident #1 then pushed her to the side, stating, What the hell, lady.
Both residents were immediately separated, assessed and placed on frequent checks.
Dietary aide (DA) #1 witnessed the incident and reported that Resident #2 wanted Resident #1 to back up, but he cussed her out. DA #1 stated, I moved Resident #1 forward and away.
During a post-incident interview, Resident #1 responded, I do not know why she slapped me; she is crazy.
Interviews substantiated the physical abuse by Resident #2 toward Resident #1.
C. Resident #2 - assailant
1. Resident status
Resident #2, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included schizoaffective disorder (depressive type), anxiety disorder and Alzheimer's disease.
The 1/21/25 minimum data set (MDS) assessment revealed Resident #2 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. She required the assistance of one person with transfers, dressing, showering, toileting, and personal hygiene.
The MDS assessment documented Resident #2 had physical behavioral symptoms directed toward others which occurred every one to three days during the assessment period.
2. Record review
The behavioral care plan, initiated on 12/24/19 and revised on 1/21/25, documented Resident #2 had targeted behaviors of paranoia and could have a short temper. The care plan documented when the resident was cycling, she would make false accusations, believing staff were talking about her and making fun of her. Resident #2 had hit people in the past due to being short tempered and having impulsive responses. The interventions included providing one-to-one conversations with staff to discuss her feelings, assisting the resident out of the middle of the hallway, encouraging her to travel on one side of the hallway to mitigate disruptive interactions with others, assigning a one-to-one caregiver for emotional support, speaking to the resident calmly, educating the resident to stay away from people she did not get along with and administering and monitoring medications as ordered.
-The facility failed to update Resident #2's care plan after the incident of physical abuse on 2/26/25.
The 1/2/25 progress note documented Resident #2 was in the hallway self-propelling in her wheelchair. Resident #13 was waiting for Resident #2 to pass when Resident #2 hit him in the middle of his chest. Resident #2 yelled Get out of my way. Resident #13 said he put his hand on Resident #2's head to stop her and said, stating What the hell old lady. Resident #2 stated she was trying to stop Resident #13 from bumping into her. An assessment was completed and no injuries were noted. Both residents were placed on frequent safety checks.
The 2/26/25 progress note revealed Resident #2 slapped Resident #1 in the face while passing in the hallway to the dining room. Resident #2 refused to talk about the incident and continued yelling at the staff. A head-to-toe assessment was completed for both residents and no physical injuries were noted. Both residents were separated and placed on frequent checks. The facility notified the residents' families and the ombudsman and made an online police report.
D. Resident #13 - victim
1. Resident status
Resident #13, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 CPO, diagnoses included type 1 diabetes mellitus and end-stage renal disease.
The 2/12/25 MDS assessment documented Resident #13 was cognitively intact with a BIMS score of 13 out of 15. He was independent with bed mobility, eating, toileting, personal hygiene and dressing.
E. Resident #1 - victim
1. Resident status
Resident #1, age [AGE], was admitted on [DATE]. According to the March 2025 CPO, the diagnoses included acute and chronic respiratory failure, unspecified encephalopathy, alcohol use disorder and an acquired absence of right leg above the knee.
The 1/16/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 10 out of 15. He required assistance from two people with transfers. He required assistance of one to two people with dressing, toileting and personal hygiene.
F. Staff interviews
Certified nurse aide (CNA) #3 was interviewed on 3/25/25 at 5:10 p.m. CNA #3 said Resident #2 yelled, screamed, and tried to scratch other residents and staff members often. She said she would give Resident #2 space when she was having a bad day. CNA #3 said every time Resident #2 had a bad day, the facility staff did not walk with the resident down the hallway. She said it was easier to give her space so they did not get hit or scratched. She said she did not try to walk between Resident #2 and any other residents coming down the hallway to ensure another resident was not targeted by Resident #2. She said was concerned if she was too close to Resident #2 during those episodes, she would get hit or scratched.
CNA #3 said Resident #2 did not always like it when other residents invaded her personal space and got too close. She said Resident #2 could become physically aggressive if that happened.
Registered nurse (RN) #3 was interviewed on 3/25/25 at 5:25 p.m. RN #3 said the facility staff gave Resident #2 space and would backup away from her when she was upset. She said Resident #2 was physically aggressive when she was having a bad day. She said Resident #2 could be physically aggressive with facility staff or toward other residents. She said she was concerned if she got too close to Resident #2 during a bad day, she would be hit.
RN #3 said the facility staff did not provide Resident #2 with a one-to-one supervisor when she moved about the facility. She said facility staff did not walk down the hallway to follow the resident and stand between Resident #2 and another resident coming down the hallway if Resident #2 was having a bad day. She said Resident #2 did not like other residents getting too close to her.
RN #3 said if Resident #2 was physically aggressive with another resident, she would be placed on 15-minute safety checks for three days.
The DON, the NHA, the clinical consultant (CC) and the regional operations manager (ROM) were interviewed together on 3/26/25 at 1:36 p.m. The DON said Resident #2 had a history of physically aggressive behavior towards other residents and staff members. She said she had been institutionalized at a young age and had a difficult time trusting others. She said Resident #2 was very protective of her belongings and personal space. She said Resident #2 did the best when she was regimented in a daily routine.
The DON said Resident #2 would get triggered by what she perceived as another resident getting too close to her, especially in areas such as the hallway. She said the resident had a large personal bubble that was not always obvious to others and she was paranoid about people whispering or talking about her behind her back.
The NHA said there were a few staff she trusted and she had built a good relationship with them. He said she was part of a program through her insurance that would provide a one-to-one companion once or twice a week for one to two hours.
The DON said if Resident #2 was having a bad day, the floor staff should notify management and someone she trusted and had a good rapport with would go down and sit with her. She said staff should keep an eye on Resident #2 when she left her room often, because that could be a sign of a bad day. She said the floor staff should walk down the hallway in between Resident #2 and another resident to ensure the other resident did not get too close to Resident #2 in order to prevent an altercation.
Cross reference F744: the facility failed to provide effective dementia care to Resident #2 to prevent potential physical altercations toward other residents.
The NHA said Resident #2 was willful in the incidents of physical abuse toward Resident #1 and Resident #13.
Jan 2024
18 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure the self-administration of medications was cl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#79) of one out of 52 sample residents.
Specifically, the facility failed to ensure Resident #79 was assessed for safe self-administration of medications.
Findings include:
I. Facility policy and procedure
The Self-Administration of Medications policy, revised February 2021, was provided by clinical nurse consultant (CNC) #1 on 1/27/24 at 4:58 p.m. It revealed in pertinent part, Residents have the right to self-administer medication if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.
As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.
Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room.
Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.
II. Resident #79
A. Resident status
Resident #79, under the age of 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), anxiety and alcohol abuse.
The 11/7/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required set-up assistance for eating. He was independent with oral hygiene, toileting, upper body dressing and personal hygiene. He required partial assistance for showering.
B. Observations and record review
On 1/17/24 at 10:41 a.m., Resident #79 was lying in bed. On Resident #79's bedside table there was a medication cup with four pills in it and a medication cup with a liquid protein supplement. The resident said he had instructed the nursing staff to leave them on the table as he was not ready to take his medications.
On 1/22/23 at 9:28 a.m., Resident #79 had a cup with pills in it on his bedside table.
On 1/23/24 at 9:28 a.m., there was a cup with four pills and a cup of liquid protein supplement on Resident #79's bedside table.
-At 10:30 a.m. the unit manager (UM) entered Resident #79's room. She said there were two medicine cups on the resident's bedside table. The UM said it appeared the resident had taken the medications.
-A review of the resident's electronic medical record (EMR) did not reveal an assessment for self-administering of medications, a physician order for self-administration of medications or a care plan regarding self-administration of medications.
III. Staff interviews
The UM was interviewed on 1/23/24 at 10:17 a.m. The UM said residents need an assessment, a physician order and a care plan in order to self-administer medications. The UM said the licensed nurses should not leave medications on residents' bedside tables.
The director of nursing (DON) was interviewed on 1/23/24 at 1:29 p.m. The DON said an evaluation must be completed in order to determine if a resident was able to self-administer medications. The DON said if it was determined the resident could self-administer medications the medications needed to be in a locked box. The DON said there needed to be a physician's order for the self-administering of the medications.
The DON said the licensed nurses should stay with the resident until the medications were consumed if the resident had not been deemed appropriate to self-administer medications. The DON said if the resident was not ready to take the medication the licensed nurse should have removed the medication from the resident's room until the resident was ready for the medications.
The DON was interviewed again on 1/24/24 at 4:51 p.m. with the CNC #1 present during the interview.
The DON said Resident #79 had not been assessed to self-administer medications. The DON said the licensed nurses should not have left medications on Resident #79's bedside table.
CNC #1 said she was going to educate the licensed nurses on not leaving medications with a resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to resolve any grievances for one (#16) of one resident reviewed for grievan...
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Based on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to resolve any grievances for one (#16) of one resident reviewed for grievances out of 52 sample residents.
Specifically, the facility failed to ensure grievances regarding missing clothing items was followed up timely with a satisfactory resolution for Resident #16.
Findings include:
I. Facility policy
The Grievance policy, dated 5/8/23, was provided by corporate nurse consultant (CNC) #1 on 1/24/24 at 3:15 p.m. It read in pertinent part, To provide residents and responsible parties with information on the facility grievance procedure. To ensure that residents are afforded their right to file a grievance without discrimination or reprisal and that such grievance shall be responded promptly and in written form.
Upon the receipt of a grievance and complaint report or complaint concern form, the social service director or designee will begin an exploration into the allegations/concerns. The appropriate department director will be notified of the nature of the complaint that follow up is necessary.
The resident or person acting on behalf of the resident will be informed of the findings of the investigation, as well as any corrective actions recommended within 10 working days of the filing of the grievance or complaint.
II. Resident representative interview
Resident #16's representative was interviewed on 1/23/24 at approximately 4:56 p.m. The representative said that Resident #16 had missing clothes. She said the clothing items were not returned from the laundry or were in other resident's closets and the other residents were wearing the clothes. She said she had purchased replacement clothes for Resident #16 and turned in the receipts to the previous nursing home administrator (NHA). Resident #16's representative said she did not get any response regarding the missing clothes or reimbursement for them from the previous NHA. She said she had spoken to the current NHA several months prior but had not received reimbursement or a resolution response from him. Resident #16's representative said was frustrated with the lack of resolution to her concern about the resident's missing clothing items.
III. Record review
-The facility did not have a record of the grievance for Resident #16's missing clothing items.
-A grievance form was completed for the missing clothing items on 1/23/24, during the survey.
IV. Additional interviews
The social service director (SSD) was interviewed on 1/24/24 at approximately 9:00 a.m. The SSD said she had started her employment two weeks prior, and was familiarizing herself with the residents. She said she was not able to locate a grievance form for Resident #16's missing clothing items. She said she filled out a grievance form on 1/23/24 and would ensure the missing clothing concern was resolved.
The business office manager (BOM) was interviewed on 1/24/24 at 5:15 p.m. The BOM said Resident #16's representative had spoken to her about the missing clothing items, however, she said she was not able to replace the clothes until the concern went through the facility's grievance process. She said the resident's representative had been waiting for reimbursement for a long time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to take steps to protect one (#6) of three residents out of 52 sample...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to take steps to protect one (#6) of three residents out of 52 sample residents.
Specifically, the facility failed to ensure Resident #6 was free from physical abuse from Resident #11.
Findings include:
I. Facility policy and procedure
The Abuse policy, dated 5/3/23, was provided by clinical nurse consultant (CNC) #1 on 1/17/24 at approximately 11:00 a.m. It revealed in pertinent part, Purpose: Communities does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals.
Intent: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms.
Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Also, verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through use of technology.
Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and wilful neglect of the resident's basic needs.
II. Incident of physical abuse between Resident #6 and Resident #11 on 12/30/23
The 12/30/23 abuse investigation documented there was a physical altercation between two residents at 5:15 p.m. The residents were separated and placed on frequent checks. The victim (Resident #6) was assessed and treated by staff. The investigation documented Resident #6 had a diagnosis of aphasia (loss of speech), schizoaffective disorder (mental health disorder) and a history of a traumatic brain injury. Resident #6 had severely impaired cognition and was wheelchair bound. Resident #6 had a history of verbal and physical aggression related to emotion dysregulation due to her traumatic brain injury. The investigation documented Resident #6 had a care plan that addressed her behaviors. Resident #11 had a diagnosis of aphasia and vascular dementia. Resident #11 had severely impaired cognition and was wheelchair bound. Resident #11 had a history of verbal and physical aggression, tearfulness and declining care. The investigation documented the resident had a care plan that addressed the resident's behaviors. Resident #11 grabbed Resident #6's arm. Licensed practical nurse (LPN) #2 assessed Resident #6 and no injuries were found. Resident #6 remained at baseline.
The investigation documented the social services director (SSD) interviewed Resident #6 on 1/2/24 at 1:00 p.m. with a series of yes or no questions. Resident #6 said Resident #11 grabbed her arm and yelled at her.
-The interview did not indicate if Resident #6 had pain or was afraid of Resident #11.
The investigation documented the SSD interviewed Resident #11 on 1/2/24 at 12:00 p.m. with a series of yes or no questions. Resident #11 did not remember the incident on 12/30/23.
The investigation documented certified nurse aide (CNA) #4 witnessed the 12/30/23 incident between Resident #6 and Resident #11. CNA #4 said Resident #11 was in the doorway of the chapel and Resident #6 was in the hallway. CNA #4 said Resident #6 was in the way and Resident #11 said come on. CNA #4 said Resident #6 said something back to Resident #11. CNA #4 said Resident #11 then reached out and grabbed Resident #6. CNA #4 said she separated the residents and reported the altercation to both of the resident's nurses.
Four residents were asked the following questions and had no concerns:
-Have you ever been treated roughly by staff, other residents, or anyone else at the home?
-Have staff, other residents or anyone else at the home yelled or been rude to you? and,
-Do you ever feel afraid because of the way you or some other resident is treated?
The summary of the investigation documented the residents and the witness were interviewed. The risk management was reviewed and policies and procedures were followed. Resident #6's care plan was updated to include interventions for behavior management. The summary documented the care plan for Resident #6 remained accurate. Resident #11 was educated on emotional regulation and his care plan was updated to include behavior management techniques.
-A review of Resident #6's comprehensive care plan did not indicate updates were made to her care plans to prevent further altercations from occurring.
The summary of the investigation documented the altercation occurred, but did not substantiate abuse occurred due to no injury being present.
-However, physical abuse did occur due to Resident #11's willful (deliberate) action of grabbing Resident #6's arm and yelling at her.
III. Resident #6
A. Resident status
Resident #6, under the age of 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included history of traumatic brain injury, vascular dementia, behavioral disturbance and schizoaffective disorder bipolar type (episodes of mania and depression).
The 11/22/23 minimum data set (MDS) assessment revealed the resident had short-term and long-term memory deficits with a staff interview for mental status. The resident required set-up assistance for eating and oral hygiene. The resident was dependent on staff for toileting, showering, upper and lower body dressing and personal hygiene.
The MDS assessment documented the resident usually made herself understood, usually understood others and had unclear speech.
The MDS assessment documented the resident did not have physical or behavioral symptoms directed towards others. The assessment documented the resident had other behavioral symptoms not directed towards others.
B. Record review
-A review of Resident #6's electronic medical record (EMR) did not reveal documentation that she was grabbed by Resident #11 on 12/30/24.
The 12/30/23 nursing-weekly skin assessment was documented at 4:16 p.m. (prior to the incident of Resident #11 grabbing Resident #6) revealed the resident did not have any skin issues.
-A review of Resident #6's EMR did not reveal monitoring of Resident #6 for latent injury.
The behavior care plan, initiated on 8/12/22 and revised on 12/29/23, revealed Resident #6 had a history of schizoaffective disorder and history of a traumatic brain injury that created behavioral challenges. The resident had a history of verbal aggression against staff members and would become aggressive when it came to money and smoking cigarettes. Resident #6's conservator said Resident #6 did not like being on a tight budget and it upset her. Resident #6 was a supervised smoker which was frustrating to her. Resident #6 called out loudly when she was upset and had the potential to disturb other residents. Resident #6 had a history of taking and opening packages from the front desk and taking them to her room. Pertinent interventions included: administering medications as ordered, anticipating and meeting the resident's needs, assisting the resident to develop more appropriate methods of coping and interacting, encouraging the resident to express her feelings appropriately, providing behavioral health services, providing opportunity for positive interaction and attention, explaining all procedures to the resident prior to starting, discussing the residents behavior, monitoring for behavior episodes and praising any indication of the residents improvement in behaviors.
The communication care plan, initiated on 5/5/22 and revised on 11/21/23, revealed the resident had a communication problem related to aphasia (difficulty speaking). Resident #6 was able to make her needs known and was usually understood. The interventions included: anticipating and meeting the resident's needs, allowing adequate time to respond, allowing the resident to respond to yes/no questions or with a few words, using the English language and using the communication board and gestures to communicate.
The impaired cognition care plan, initiated on 6/30/23 and revised on 7/31/23, revealed Resident #6 had impaired cognitive function related to vascular dementia and a history of traumatic brain injury. Resident #6 had a guardian in place to support her with medical decision making. The interventions included: administering medications as ordered, using the residents preferred name, cueing and reorienting as needed and monitoring for changes in cognition.
The mobility care plan, initiated on 5/16/22 and revised on 6/19/23, revealed Resident #6 had limited physical mobility related to right sided weakness. Resident #6 was able to move her wheelchair around the facility. The interventions included monitoring and documenting signs or symptoms of immobility, providing gentle range of motion as tolerated with daily care and providing supportive care and assistance with mobility as needed.
C. Resident interview and observations
Resident #6 was interviewed on 1/18/24 at 11:03 a.m. Resident #6 said she recalled the incident of Resident #11 grabbing her. Resident #6 pointed to her right forearm and said he grabbed her there. Resident #6 said it hurt and it caused bruising. Resident #6 said she was afraid of the Resident #11.
On 1/23/24 at 4:57 p.m. Resident #6 was in the common area on the south unit. Resident #6 said she was waiting to smoke. Resident #6 was by the posted assisted smoking times schedule.
-At 4:58 p.m. the activities director (AD) told Resident #6, she had to wait until 5:30 p.m. to smoke. Resident #6 became upset and raised her voice.
IV. Resident #11
A. Resident status
Resident #11, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 CPO, diagnoses included vascular dementia, anxiety, aphasia (difficulty speaking), and epilepsy (seizure disorder).
The 11/7/23 MDS assessment revealed the resident was unable to complete the BIMS assessment. The resident required partial assistance with oral hygiene and personal hygiene. The resident required substantial assistance for toileting, showering and dressing.
The MDS assessment documented the resident usually understood others and usually made himself understood. The MDS assessment documented the resident did not have physical or verbal behaviors directed towards others during the review period.
B. Record review
-A review of Resident #11's EMR did not reveal documentation that he grabbed Resident #6 on 12/30/24.
The behavior care plan, initiated on 2/6/18 and revised on 1/4/24, revealed Resident #11 had a history of behavior challenges related to anger issues and frustration with his current situation. Resident #11 could exhibit shakiness, crying and be verbally and physically aggressive with the progression of dementia and history of a stroke. Resident #11 used physical touch as a way to communicate which was not always received well by others. Resident #11 had received education not to touch other residents or staff without their consent. Resident #11 traveled backwards in his wheelchair and had been educated to go slow and watch his surroundings to prevent injury. Resident #11 had a history of declining care. Resident #11 responded well to eating out for behavior management. The interventions included: offering Resident #11 to eat out for lunch if he was having behaviors (1/4/24), conducting a medication review as needed (5/16/23), monitoring for signs of agitation and encouraging the resident to go to a quiet area (6/17/23), offering and encouraging dark sunglasses when he was out of his room during the day (5/16/23), reviewing medications quarterly with the interdisciplinary team and attempting gradual dose reductions when clinically indicated (5/16/23), providing additional support through social services (12/29/23), redirecting the resident to a less stimulating environment when he showed signs of aggression or anxiety (5/16/23), anticipating and meeting the residents needs (2/6/18), providing the opportunity for positive interaction and attention (5/16/23), encouraging the resident to express his feelings appropriately (5/16/23), explaining all procedures to the resident prior to starting care (2/6/18), discussing the resident's behavior if reasonable (2/6/18) and minimizing the potential for disruptive yelling behaviors by offering tasks which divert attention (5/16/23).
-The intervention of offering Resident #11 to eat out for lunch if he was having behaviors was initiated on 1/4/24 after the incident of Resident #11 grabbing Resident #6. The 12/30/23 altercation occurred in the evening around 5:00 p.m. and was not around lunch time.
The cognitive impairment care plan, initiated on 10/9/17 and revised on 5/26/22, revealed Resident #11 had impaired thought processes related to pseudobulbar effects (episodes of uncontrolled laughing or crying). Resident #11 was alert and oriented to self, time and place. Resident #11 had actual communication deficits related to history of a stroke, pseudobulbar effects and aphasia. Resident #11 was usually able to express ideas and wants. Resident #11 was able to understand verbal content. Resident #11 needed time to express ideas and wants. Resident #11 sometimes became frustrated when unable to express verbal content. Resident #11 had potential for behaviors related to pseudobulbar effects. Resident #11 had a history of verbal aggression towards staff. The interventions included: communicating with the resident and his family regarding his capabilities, providing verbal cues and gestures during activities to complete a task, reminiscing with the resident using photos of family and friends, reviewing medications and recording possible causes of cognitive deficit, using task segmentation to support short term memory deficits and visiting with the resident often using yes or no questions.
The communication care plan, initiated on 10/9/17 and revised 8/16/23, revealed Resident #11 had a communication problem related to history of a stroke. Resident #11 was able to make his needs known through staff asking a series of yes and no questions. Resident #11 used physical touch, hand gestures and some speech to communicate his needs. Resident #11 had a communication board but declined to use it. The interventions included: anticipating and meeting the residents needs, being conscious of the resident's position when in groups to promote proper communication with others, discussion with the resident and his family about concerns or feelings regarding his communication difficulty, providing verbal cues and gestures for tasks during activities, encouraging the resident to continue starting thoughts even when he was having difficulties, monitoring for physical and nonverbal indication or discomfort or distress, reviewing factors affecting the underlying cause of his communication deficit and speaking slowly and clearly on an adult level.
V. Staff interviews
LPN #4 was interviewed on 1/23/24 at 3:40 p.m. LPN #4 said Resident #6 liked to smoke. LPN #4 said Resident #6 became agitated if the staff were late to help her smoke.
LPN #4 said Resident #6 and Resident #11 had a history of behaviors. LPN #4 said she was not aware that Resident #11 grabbed Resident #6 on 12/30/23.
LPN #4 said when there was suspected abuse she would notify her supervisor immediately.
The SSD was interviewed on 1/23/24 at 3:57 p.m. The SSD said she worked alongside the nursing home administrator (NHA) to complete abuse investigations. The SSD said she completed the abuse investigation for the altercation between Resident #11 and Resident #6 on 12/30/23. The SSD said the NHA and she determined abuse did not occur because no injury occurred. The SSD said the incident did occur as it was witnessed by CNA #4.
The SSD said the residents were separated and placed on frequent checks. The SSD said Resident #6 was seen by behavioral health services routinely for monitoring. The SSD said the nurse practitioner for behavioral health services monitored Resident #6 for changes after the altercation.
The SSD said she was not aware Resident #6 was afraid of Resident #11. The SSD said Resident #6 and Resident #11 had a history of behaviors.
The SSD said both Resident #6 and Resident #11 had a difficult time communicating. The SSD said she believed Resident #11 was unable to ask Resident #6 to move out of his way, so he grabbed her.
The SSD said she did not update Resident #6 or Resident #11's care plans. The SSD said she thought the current care plans were effective. The SSD said new interventions were not put in place to keep Resident #6 and Resident #11 safe. The SSD said Resident #6 was involved in another altercation this week (during the survey), where Resident #6 was the assailant and hit another resident.
The SSD said Resident #6 often became agitated when she was not assisted to smoke at the correct smoking time.
Corporate consultant (CC) #1, CNC #1 and CNC #2 were interviewed together on 1/24/24 at 4:17 p.m. CC #1 said he was not a part of the investigation for the 12/30/23 occurrence but was aware of the situation. CC #1 said Resident #11 and Resident #6 had a difficult time communicating with each other.
CC #1 said the regulations were frequently changing on what needed to occur for abuse to be substantiated.
CC #1 said Resident #6 had bad vision. CC #1 said the facility believed her vision was causing agitation so they had the eye doctor assess her on 1/24/24. CC #1 said he was hoping this would help Resident #6 feel more comfortable in her surroundings.
CC #1 said they would look at the smoking times to ensure Resident #6 was assisted promptly at the smoking times to help reduce agitation.
CNC #1 said she reviewed Resident #6 and Resident #11's EMRs. CNC #1 said the EMRs for both residents did not document that the altercation occurred on 12/30/23. CNC #1 said the altercation needed to be included in the medical records.
CNC #2 said the facility charted by exception (documenting only what was outside the normal or usual for a resident). CNC #2 said there were no injuries when the altercation occurred therefore she did not expect the licensed nurse to document anything. CNC #2 said the facility should have monitored Resident #6 for latent injuries.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents received pre-admission mental health screenings f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents received pre-admission mental health screenings for one (#24) of one resident reviewed for mental health screenings out of 52 sample residents.
Specifically, the facility failed to perform a level two pre-admission screening and resident review (PASRR) for Resident #24.
Findings include:
I. Facility policy and procedure
The PASRR policy, created 9/26/23, was received from the corporate nurse consultant (CNC) on 1/29/24 at 12:29 p.m. It read in pertinent part: If a Level II is needed, this will be scheduled and completed and (name of partner with government agency) will provide recommendations that should then be filed in the facility's record along with all other PASRR documents.
II. Resident #24
A. Resident status
Resident #24, age younger than 65, was admitted to the facility on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included mild cognitive impairment, depressive episodes, insomnia, schizoaffective disorder.
The 10/31/23 minimum data assessment (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was independant and did not require supervision or assistance with activities of daily living.
The assessment indicated Resident #24 had depression. The MDS did not indicate that the resident was diagnosed with schizoaffective disorder or an anxiety disorder.
B. Record review
Review of Resident #24's care plan for antipsychotic medication, initiated 8/29/23 and revised 8/30/23 revealed the resident was on the medication to treat symptoms and behaviors associated with schizoaffective disorder. Interventions included behavior monitoring, non-pharmacological interventions, and consulting with the pharmacy and physician at least quarterly to consider a dosage change for the resident.
-The care plan failed to document a Level II PASRR for Resident #24.
Review of progress notes from behavioral services (BHS) revealed the following:
The 7/18/23 progress note fromBHS documented Resident #24 had a pending level II PASRR evaluation.
The 8/29/23 progress notes from BHS documented Resident #24 was diagnosed with schizoaffective disorder on 8/29/23 and recommended the resident receive a PASRR Level II screening as soon as possible.
The BHS progress notes from 9/5/23 to 10/23/23 recommended the resident receive a PASRR Level II screening as soon as possible.
The 11/20/23 progress note from BHS documented the behavioral health clinician tried to obtain a PASRR Level II evaluation with the the facility for Resident #24 due to her schizoaffective disorder.
The 1/8/24 progress note from BHS documented the behavioral health clinician tried to discontinue Resident #24's psychiatric medications and obtain a PASRR Level II evaluation with the facility for the resident to confirm her schizoaffective disorder.
Review of the quarterly social service evaluations revealed the following:
The 8/9/23 quarterly social service evaluation note documented Resident #24 had an approved Level I PASRR but did not indicate the resident had a Level II PASRR.
The 10/26/23 quarterly social service evaluation note documented Resident #24 had an approved Level I PASRR but did not indicate the resident had a Level II PASRR.
B. Staff interviews
The social services director (SSD) was interviewed on 1/23/24 at 2:00 p.m. The SSD said she had started her employment two weeks ago and was familiarizing herself with the residents. She said when a resident had a major mental illness a PASRR Level II needed to be completed.
The SSD was interviewed a second time on 1/24/24 at approximately 11:00 a.m. The SSD said she had requested a Level II PASRR for Resident #24 due to his major mental disorder diagnosis of schizoaffective disorder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#79) of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#79) of one resident reviewed for discharge planning out of 52 sample residents.
Specifically, the facility failed to assist Resident #79 with his discharge planning goals.
Findings include:
I. Facility policy and procedure
The Discharge Planning policy, dated [DATE], was provided by the clinical nurse consultant (CNC) #1 on [DATE] at 12:03 p.m. It revealed in pertinent part, The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals. This will include identifying ways for residents to be active participants and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions.
Discharge planning is a process that begins on admission and involves identifying the resident's discharge goals and potential barriers, developing and implementing interventions to address them, and continuously evaluating the plan throughout the resident's stay to ensure a successful discharge.
The facility will evaluate the resident's expected goals for discharge upon admission, then routinely in accordance with the MDS (minimum data set) assessment cycle, and as needed. Initial information and discharge goals will be included in the resident's baseline care plan. Subsequent information and discharge goals will be included in the resident's comprehensive plan of care with updates completed as needed.
If discharge to community is identified to be the resident/representative's goal, an active discharge care plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative.
The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications.
II. Resident #79
A. Resident status
Resident #79, under the age of 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), anxiety and alcohol abuse.
The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required set-up assistance for eating. He was independent with oral hygiene, toileting, upper body dressing and personal hygiene. He required partial assistance for showering.
The MDS assessment indicated an active discharge plan was not in place. The resident wanted to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community. A referral had been made to a local contact agency.
B. Resident interview
Resident #79 was interviewed on [DATE] at 10:39 a.m. Resident #79 said his goal was to return to the community. The resident said he was participating in the transitions program. Resident #79 said the social worker or other staff members at the facility had not discussed discharge planning with him for several months. Resident #79 said he needed assistance with his discharge planning.
Resident #79 said he felt that he was being warehoused at the facility until he died because no one was communicating with him or assisting him with his discharge goals.
C. Record review
The discharge care plan, initiated on [DATE] and revised on [DATE], revealed the resident would be staying at the facility for long term care. The interventions included: discussing the resident's current living arrangements and desire for discharge to the community periodically and as needed, introducing the resident to peers and tablemates as needed and inviting the resident to activities of choice.
The [DATE] social services note documented the social worker sent a referral to the transitions program for the resident.
The [DATE] social services progress note indicated, in pertinent part, Resident #79 went to the social services office and was upset that he was not living independently. The social services director (SSD) informed the resident that he had been referred to the transitions program.
The [DATE] social services progress note documented the SSD reached out to the transitions program to determine the status of Resident #79's transition to the community. The transitions program coordinator informed the SSD that Resident #79 did not have active long-term care Medicaid when the referral was submitted. The transitions program coordinator informed the SSD that Resident #79 was unable to begin the transitions program until the long-term care Medicaid was in effect. The note documented the SSD checked in with the business office manager who said Resident #79 was approved for long-term Medicaid approximately two weeks ago. The SSD sent a new application for the transitions program on [DATE] (during the survey).
III. Staff interviews
The SSD was interviewed on [DATE] at 4:27 p.m. The SSD said she had recently started working at the facility and had not metResident #79.
The SSD said the discharge planning process began upon admission. The SSD said the residents discharge goals should be reviewed quarterly and documented in the resident's electronic medical record and be included in their comprehensive care plans.
The SSD said she reviewed the resident's medical record and the resident was referred to the transitions program in [DATE]. The SSD said she could not find any further documentation that indicated the resident was updated on the status of the transitions program.
The SSD was interviewed again on [DATE] at 12:01 p.m. The SSD said she reached out to the transitions program coordinator to get an update on Resident #79's referral from [DATE]. The SSD said the program coordinator informed her that the resident did not qualify for the transitions program since he did not have long-term care Medicaid. The SSD said she spoke with the business office manager who informed her that the resident was approved for Medicaid approximately two weeks ago. The SSD said the facility had not sent in a new referral for the transitions program for Resident #79 until today ([DATE]). The SSD said she would follow-up with the resident and update him on the status of his transition program referral.
The director of nursing (DON) and the CNC #1 were interviewed together on [DATE] at 1:29 p.m. The DON said she was aware Resident #79 wanted to discharge to the community. CNC #1 said the resident did not have Medicaid, so the resident did not qualify for the transitions program.
CNC #1 said the resident was approved for Medicaid two weeks ago.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to mai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#79) of two residents reviewed for vision out of 52 sample residents.
Specifically, the facility failed to offer vision services to Resident #79.
Findings include:
I. Facility policy and procedure
The Ancillary services policy, dated 11/4/13, was provided by the clinical nurse consultant (CNC) #1 on 1/23/24 at 1:02 p.m. It revealed in pertinent part, Purpose: Ancillary services, including, but not limited to, dental, vision, audiology and podiatry will be provided to the resident per state and federal regulatory guidelines; at the resident/responsible family members request; and as needed.
Ancillary services are available to all residents requiring routine and emergency ancillary services care.
Social Services/Designee will be responsible for ensuring residents needing ancillary services receive needed/requested services in a timely manner.
Records of Ancillary services care will be kept in the resident's medical record for a period of one year.
II. Resident #79
A. Resident status
Resident #79, under the age of 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), anxiety and alcohol abuse.
The 11/7/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required set-up assistance for eating. Resident #79 was independent with oral hygiene, toileting, upper body dressing and personal hygiene. Resident #79 required partial assistance for showering.
The MDS assessment indicated the resident had adequate vision and had corrective lenses.
B. Resident interview
Resident #79 was interviewed on 1/17/24 at 10:49 p.m. Resident #79 said he had glasses. Resident #79 said the prescription in his glasses was very old and he needed new glasses. Resident #79 said he had not been offered the opportunity to see an eye doctor. Resident #79 said he had a hard time doing things he enjoyed like watching television because he was unable to see.
C. Record review
A request was made for Resident #79's most recent optometrist (eye doctor) visit progress note. The social services director (SSD) said the resident had not been seen by the optometrist since he was admitted to the facility in August 2023.
-A review of Resident #79's comprehensive care plan revealed the resident's vision needs were not included in the plan of care.
III. Staff interviews
The SSD was interviewed on 1/22/24 at 10:34 a.m. The SSD said she was responsible for ensuring ancillary services, such as vision, were offered and provided to the residents.
The SSD said the eye doctor typically came every other month and his next visit to the facility was scheduled for 2/1/24.
The SSD said ancillary services should be offered upon admission, quarterly and as needed. The SSD said she recently started working at the facility and was not aware Resident #79 needed to see the eye doctor. The SSD said she would ensure the resident was seen by the eye doctor on the next visit to the facility.
The SSD said she was unable to locate documentation indicating the resident had been seen by the eye doctor or had been offered vision services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #38
A. Resident status
Resident #38, age over 65, was admitted on [DATE]. According to the January 2024 CPO, diagn...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #38
A. Resident status
Resident #38, age over 65, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included chronic osteomyelitis (bone infection), chronic pain, osteoarthritis in the hands, anxiety, unstageable pressure ulcer of the sacrum, stage 4 right shoulder pressure injury, stage four right hip pressure injury and stage 4 pressure ulcer of the left heel.
The 12/8/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment documented the resident had two stage 4 pressure injuries. The resident was on a pain medication regimen and had frequent pain which occasionally affected her day-to-day activities.
B. Record review
Resident #38's January 2024 CPO revealed the following physician orders for pain management:
-Monitor the resident's pain every shift using 0-10 scale. The order date was 1/13/24.
-Administer PRN pain medication 30 minutes prior to wound care. The order date was placed on 5/8/23.
The January 2024 CPO revealed orders for current pain control included:
-Methadone HCl 5 mg oral tablet by mouth twice daily. The order date was 1/12/24;
-Morphine Sulfate oral tablet extended release 15 mg every eight hours. The order date was 11/15/23;
-Morphine Sulfate (concentrate) oral solution 100mg/ml, give 0.5 milliliters (ml) every one hour as needed for pain. The order date was 5/24/23.
The pain care plan, revised on 5/16/23, identified the resident had chronic pain from chronic osteomyelitis documented interventions included administering analgesia as ordered, evaluate the effectiveness of pain interventions within one hour, and record pain characteristics every shift and PRN: including quality, severity, anatomical location, onset, duration, aggravating factors, and relieving factors. The care plan also documented to offer non pharmacological interventions for pain prior to medication and PRN medication: including offer a snack, drink, redirect to an activity, offer independent activity supplies, offer to call a loved one, assist outside, sit with resident as needed, offer shower or bath, active listening and validation, offer range of motion, massage, relaxation, breathing techniques, imagery, distraction, repositioning, aromatherapy, and therapeutic touch.
-The medical record failed to show any non-pharmacological interventions were used.
-On 1/1/24, 1/4/24, 1/6/24, 1/8/24, 1/13/24, 1/15/24, 1/18/24 and 1/22/24 documented the resident had no PRN pain medication administered prior to wound care.
The January 2024 MAR was reviewed from 1/1/24 through 1/22/24 and showed the resident's pain was over the pain goal (two out of 10) 14 times. Nine of those times, there was no follow up pain assessment after the PRN pain medication was administered.
The quarterly pain evaluation was completed on 8/1/23. The pain evaluation showed her pain goal was two out of 10.
-The pain evaluation was missing the component of precipitating, aggravating and relieving factors for pain.
C. Staff interviews
LPN #6 was interviewed on 1/24/24 at 9:30 a.m. LPN #6 said anytime Resident #38 was approached by someone, she complained about being in pain. She said the resident was sleeping most of the time and did not call often.
LPN #6 was interviewed on 1/24/24 at 1:35 p.m. LPN #6 said the non-pharmacological intervention she offered for this resident was repositioning.
The hospice registered nurse (HRN) was interviewed on 1/24/24 at 3:50 p.m. He said the resident's Methadone medication was increased from 2.5 mg once a day to twice daily on 1/12/24 because of increasing pain and nerve pain in the stage 4 wounds.
The DON and CNC #1 were interviewed on 1/24/24 at 4:35 p.m. The DON said the resident should be evaluated with a complete pain assessment on admission, quarterly and with a change of condition. The DON said pain assessments should be completed every shift and as needed. She said the non-pharmacological interventions were made into their care plan on an individual basis.
The DON said Resident #38 liked relaxation, dark chocolate, water and for someone to hold her hand.
CNC #1 reviewed the complete pain assessment and said a place to document aggravating factors for pain was missing in the facility's pain assessment. CNC #1 said the nurses caring for residents who had pain should always offer non-pharmacological interventions prior to administering PRN pain medications, document the resident's stated level of pain and evaluate for effectiveness of the pain medication administered.
Based on observations, record review and interviews, the facility failed to ensure two (#38 and #79) of three residents reviewed for pain out of 52 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences.
Specifically, the facility failed to:
-Ensure Resident #79 was referred to a pain clinic in a timely manner after the physician requested a pain clinic referral;
-Thoroughly document Resident #38's pain level after administration of as needed (PRN) pain medication and the non-pharmacological interventions used prior to administration;
-Ensure prescribed PRN pain medication was administered prior to wound care according to the physician orders;
-Thoroughly and accurately complete pain assessments for Resident #38; and,
-Ensure Resident #38's pain was managed effectively according to the resident's stated pain management goal.
Findings include:
I. Facility policy
The Pain Management policy, revised 5/3/23, was provided by the director of nursing (DON) on 1/23/24 at 3:15 p.m. The policy documented in pertinent part:
Pain is subjective and is what the resident says it is, existing when and where the resident says it does. The pain evaluation will be completed upon admission, readmission, quarterly, and with any significant change in condition.
The pain evaluation includes the following: location(s), quality, intensity, associated symptoms, precipitating, aggravating and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain management and their degree of effectiveness.
All subsequent pain evaluations will be documented on the Pain Evaluation in the medical record system and/or the medication administration record (MAR) as applicable to, to include location, intensity rating, and response to pain management interventions.
When a resident complains of pain, ask the resident to rate the level of pain using the Numerical Scale using a pain level of zero (none) to ten (severe). Around the clock (ATC) dosing for continuous pain, whether it be chronic or acute, is the key to effective pain management.
Do not forget the non pharmacological interventions such as repositioning, relaxation, aromatherapy, visualization, desensitization, massage, and humor therapy. Non-pharmacological interventions should be documented in progress notes and included on the individual resident care plan.
II. Resident #79
A. Resident status
Resident #79, under the age of 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), anxiety and alcohol abuse.
The 11/7/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview of mental status (BIMS) score of 14 out of 15. The resident required set-up assistance for eating. He was independent with oral hygiene, toileting, upper body dressing and personal hygiene. He required partial assistance for showering.
The MDS assessment indicated the resident had received scheduled pain medication within the last five days and had not had pain in the last five days.
B. Resident interview and observations
Resident #79 was interviewed on 1/17/24 at 10:52 a.m. Resident #79 said he had hammer toes on both feet, chronic pain in his lower back from an accident and neuropathy in his feet. Resident #79 said he took some oral medications that helped a little bit with his pain. Resident #79 said therapy helped with his pain.
Resident #79 was interviewed again on 1/22/24 at 3:55 p.m. Resident #79 said his primary care doctor had requested the facility to send a referral to the pain clinic several months ago. Resident #79 said he never received any further communication from the facility regarding the referral.
Resident #79 was interviewed again on 1/23/24 at 10:09 a.m. Resident #79 was grabbing his legs and grimacing in pain. Resident #79 said he reported to the nurse that he was in pain.
C. Record review
The 8/21/23 long term care history and physical progress note documented the physician recommended a referral be sent to the pain clinic for the resident's pain.
The 11/6/23 nursing pain evaluation documented the resident had a medical diagnosis that would contribute to pain. The resident had mild muscle pain. The evaluation documented the resident's pain time varied and his acceptable level of pain was 0 (out of 10, with 10 being the worst pain on the scale). The resident had as needed pain (PRN) Tylenol.
The 9/18/23 physician order documented Resident #79 was to be referred to a pain clinic for evaluation and treatment for diagnosis of cervical disc degeneration.
-A review of Resident #79's comprehensive care plan revealed the resident's pain was not addressed on the resident's plan of care.
The 1/23/24 nursing progress note documented the pain clinic called to schedule an appointment for the resident on 1/24/24 at 10:10 a.m. (during the survey process).
A request was made for documentation indicating when the referral for Resident #79 was sent to the pain clinic.
-The facility did not provide the requested documentation by the end of the survey.
D. Staff interviews
Licensed practical nurse (LPN) #1 was interviewed on 1/23/24 at 10:10 p.m. LPN #1 said Resident #79 often reported pain in his hands, feet and lower back. LPN #1 said she had not worked with the resident for a couple of weeks and his medications had recently been changed but she did not know why.
LPN #5 was interviewed on 1/22/24 at 5:31 p.m. LPN #5 said Resident #79 often reported pain to her. LPN #5 said Resident #79 had medications in place to help with his pain.
The unit manager (UM) was interviewed on 1/23/24 at 10:17 a.m. The UM said the licensed nurses, the health information specialist or herself would call to make appointments for the residents. The UM said they would put the information on the communication board and the transportation director would ensure transportation was set up. The UM said she thought Resident #79 had not gone to the pain clinic yet because they were having issues with his insurance.
The UM was interviewed again on 1/23/24 at 1:24 p.m. The UM said Resident #79 was on the waiting list to get an appointment at the pain clinic.
The director of nursing (DON) and clinical nurse consultant (CNC) #1 were interviewed on 1/23/24 at 1:29 p.m. The DON said they sent a referral for Resident #79 to the pain clinic but there was a long wait. The DON said they had not attempted to refer the resident to other pain clinics. The DON said she had told the resident that she sent the referral to the pain clinic but did not document the conversation.
The medical director (MD) was interviewed on 1/23/24 at 3:47 p.m. The MD said he knew the physicians at the pain clinic. The MD said the facility should have contacted him when they were unable to get Resident #79 an appointment for several months. The MD said he would call the pain clinic and would get the resident an appointment within the week.
CNC #1 was interviewed on 1/24/24 at 2:20 p.m. CNC #1 said she was not aware the facility should have contacted the medical director in order to get Resident #79 to the pain clinic in a timely manner. CNC #1 said Resident #79 was seen by the pain clinic on 1/24/24 (during the survey). CNC #1 said the pain clinic sent handwritten orders on the back of the facesheet. CNC #1 said she was unable to utilize those orders, so she was going to call the pain clinic for clarification orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a comfortable and homelike environment for the residents on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a comfortable and homelike environment for the residents on two of two units in the facility.
Specifically, the facility failed to ensure residents were provided with clean washcloths and hand towels in their rooms on the South and North units.
Findings include:
I. Observations
On 1/17/24 beginning at approximately 9:20 a.m., the following observations were made:
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths; and,
-room [ROOM NUMBER] had no hand towels or washcloths.
On 1/18/24 at approximately 9:00 a.m., the following observations were made:
-room [ROOM NUMBER] had no hand towels or washcloths; and,
-room [ROOM NUMBER] had no hand towels or washcloths.
On 1/18/24 at 3:18 p.m., room [ROOM NUMBER] had no hand towels or washcloths.
On 1/22/24 beginning at approximately 11:00 a.m., the following observations were made:
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths; and,
-Room#52 had no hand towels or washcloths.
On 1/23/24 beginning at approximately 12:30 p.m., the following observations were made:
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels and one used washcloth;
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths;
-room [ROOM NUMBER] had no hand towels or washcloths;
-Room# 42 had no hand towels or washcloths; and,
-Room#52 had no hand towels or washcloths.
On 12/23/24 at 3:00 p.m., three linen supply closets were observed with certified nurse aide (CNA) #2 and an unidentified CNA. The observations revealed the following:
-South hall linen supply closet #2 contained only four hand towels and no washcloths;
-South hall linen supply closet #1 contained only four washcloths, four bath towels and no hand towels; and,
-North hall linen supply closet #1 contained only five hand towels and 15 washcloths.
B. Resident interviews
The resident group interview was conducted on 1/23/24 at 10:00 a.m. The group consisted of
four residents (#82, #83,#48, and #21) who were interviewable based on assessment and facility selected. Resident #82, #83, #48 and #21 all said hand towels and washcloths were not delivered to their rooms unless they asked for them.
Resident #79 was interviewed on 1/17/24 at 11:04 a.m. Resident #79 said the facility did not have enough linen hand towels or washcloths. Resident #79 said he often kept the same bath towel he used to shower with in his room because he did not have a hand towel. Resident #79 said at times he would try to shower and there were no bath towels available. He said the facility only had paper towels to supply in the residents' rooms.
-There were no hand towels or washcloths observed in Resident #79's room during the resident's interview.
Resident #26 was interviewed on 1/17/24 at 3:16 p.m. Resident #26 said the facility did not have enough hand towels or washcloths. She said the facility only provided paper towels in her room. Resident #26 said she did not like to use paper towels to dry her hands or her face. Resident #26 said linen hand towels and washcloths would make her room feel more comfortable.
-There were no hand towels or washcloths observed in Resident #26's room during the resident's interview.
Resident #59 was interviewed on 1/23/24 at 12:30 p.m. Resident #59 said she was not given a linen hand towel or washcloth very often. She said when she did get one she held onto it as she did not know when she would get another one. She said she did not like using paper towels if she did not have a linen hand towel.
-There were no towels or washcloths observed in Resident #59's room during the resident's interview.
C. Additional interviews
CNA #2 was interviewed on 1/23/24 at approximately 3:00 p.m. CNA #2 said towels and washcloths were stocked in the linen supply closets by the laundry personnel. She said once the linen supply closet was stocked it was not stocked again until the next day. She said that by the end of the day, into the evening, the linen supply closets would run out of linens. CNA #2 said the laundry department would sometimes have more linens downstairs in the laundry room but frequently they did not.
The unit manager (UM) was interviewed on 1/23/24 at approximately 3:45 p.m. The UM observed several rooms with no towels or washcloths. She said the laundry staff stocked the linen supply closets with hand towels and washcloths. The UM was not sure whose responsibility it was to ensure the hand towels and washcloths were delivered to the residents' rooms.
The corporate nurse consultant (CNC) #2 was interviewed on 1/23/24 at 4:15 p.m. CNC #2 said it was the responsibility of the CNAs to deliver hand towels and washcloths to the residents' rooms, however, she said CNAs did not complete the task daily as residents needed to request the linens. She said paper towels were always available in resident rooms. CNC #2 said the facility was going to begin asking residents their preferences for hand towels and washcloths.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents nutritional needs.
Specifically, the facility failed to:
-Follow correct p...
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Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents nutritional needs.
Specifically, the facility failed to:
-Follow correct portion sizes to ensure adequate nutrition was provided to the residents; and,
-Follow recipe modifications for minced and moist diets.
Findings include:
I. Facility policy and procedure
The Therapeutic Diets policy, revised October 2017, was provided by the clinical nurse consultant (CNC) #1 on 1/23/24 at 12:03 p.m. It read in pertinent part, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.
Diet order should match the terminology used by the food and nutrition services department.
A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet.
If a mechanically altered diet is ordered, the provider will specify the texture modification.
The attending physician may liberalize the diet at the request of the IDT (interdisciplinary term) (if the resident is losing weight or not eating well) or the resident.
II. Follow correct portion sizes
A. Observations and record review
During the lunch meal on 1/22/24, beginning at 11:00 a.m and ending at 12:45 p.m., the cook (CK) and the nutrition services director (NSD) used the following scoop sizes:
A 6 ounce (oz) ladle (0.75 cup) for the beef stroganoff for the carbohydrate controlled diet and liberalized renal diet.
A 6 oz spoodle (0.75 cup) for the egg noodles for the carbohydrate controlled diet.
-The 6 oz ladle (0.75 cup), was 2 oz more than the 4 oz specified on the menu extension sheet for the beef stroganoff for the carbohydrate controlled diet.
-The 6 oz ladle (0.75 cup), was 3 oz more than the 3 oz specified on the menu extension sheet for the beef stroganoff for the liberalized renal diet.
-The 6 oz spoodle (0.75 cup), was 3.3 oz (0.42 cup) more than the 3 oz specified on the menu extension sheet for the egg noodles for the carbohydrate controlled diet.
III. Follow recipe modifications for mechanically altered diets
A. Observations and record review
During the lunch meal on 1/22/24, beginning at 11:00 a.m and ending at 12:45 p.m.
The NSD and the cook were utilizing the 6 oz ladle of regular textured beef stroganoff for the residents who were prescribed a minced and moist diet.
The menu extension sheet specified residents who were prescribed a minced and moist diet should have received a 6 oz portion of the pureed beef stroganoff.
-The residents should have received the puree texture and not the regular texture.
V. Staff interviews
The NSD and the corporate registered dietitian (CRD) were interviewed on 1/22/24 at 4:40 p.m. The NSD said most of the residents did not want to follow the therapeutic diets. The NSD said she had not discussed liberalizing the residents' diets due to noncompliance with their diets with the residents' physicians.
The NSD said the correct texture of the beef stroganoff was not provided to the residents who were prescribed a minced and moist diet.
The CRD said the portion sizes should be followed.
The CK was interviewed on 1/23/24 at 8:50 a.m. The CK said there was a binder that had the portion sizes to follow for each diet.
The registered dietitian (RD) was interviewed on 1/24/24 at 1:10 p.m. The RD said the cooks needed to follow the diet extensions to ensure the correct portion sizes. The RD said the facility had a unique population and several of the residents had mental illness. The RD said the residents often did not want to follow the prescribed diets. The RD said the cooks should follow the portion sizes initially and if the residents wanted additional food then the cooks could provide additional portions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive at the appropriate temperatures and met the nutritional needs of the ...
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Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive at the appropriate temperatures and met the nutritional needs of the residents.
Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and appearance.
Findings include:
I. Facility policy and procedure
The Meal Preparation for Nutritive Value and Palatability policy, dated April 2023, was provided by the corporate nurse consultant (CNC) #1 on 1/23/24 at 12:59 p.m. It read in pertinent part, Food is prepared by methods that conserve nutritive value, flavor, and appearance. Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
II. Observations
A test tray for a regular diet was evaluated immediately after the last resident had been served their room tray for lunch on 1/22/24 at 12:49 p.m.by four surveyors.
The test tray consisted of beef stroganoff with egg noodles, broccoli and a fruit cocktail cup.
-The beef stroganoff was bland and tasted like raw flour;
-The egg noodles were rubbery and not fully cooked;
-The broccoli had no flavor and was mushy; and,
-The plate had a lot of loose grease on it that was not attached to food, which made the plate look unappetizing.
III. Resident interviews
Resident #79 was interviewed on 1/17/24 at 10:41 p.m. Resident #79 said the food did not look good or taste good. Resident #79 said he often skipped meals, because the food tasted or looked so bad. Resident #79 said none of the food was fresh and it was all frozen. Resident #79 said the hot foods were often served cold.
Resident #48 was interviewed on 1/17/24 at 1:27 p.m. Resident #48 said the food did not taste good. Resident #48 said the facility did not accommodate special diets.
Resident #56 was interviewed on 1/17/24 at 1:55 p.m. Resident #56 said the food did not look good or taste good. Resident #56 said the food did not look appetizing.
Resident #26 was interviewed on 1/17/24 at 3:11 p.m. Resident #26 said the food was awful. Resident #26 said all three meals were not good. Resident #26 said the taste and appearance of the food was not good.
Resident #31 was interviewed on 1/17/24 at 3:42 p.m. Resident #31 said the food was horrible. Resident #31 said the food was often cold and had no taste.
Resident #73 was interviewed on 1/17/24 at 3:48 p.m. Resident #73 said the food was terrible. Resident #73 said the taste, texture, quality and style of the cooking were bad.
Resident #77 was interviewed on 1/17/24 at 4:13 p.m. The resident said the food was not good so he often did not eat it.
Resident #38 was interviewed on 1/17/24 at 4:41 p.m. Resident #38 said the food was terrible and tasted bad.
Resident #54 was interviewed on 1/17/24 at 5:00 p.m. Resident #54 said he often skipped meals because the food tasted so bad.
Resident #3 was interviewed on 1/17/24 at 5:15 p.m. Resident #3 said her lunch today (1/17/24) was not good.
Resident #49 was interviewed on 1/17/24 at 6:11 p.m. Resident #49 said the food was not good. Resident #49 said he tried to buy all of his own food when he could.
Resident #79 was interviewed again on 1/22/24 at 3:55 p.m. The resident's meal tray remained in his room on the floor. Resident #79 said he did not want to eat the beef stroganoff because it did not look appetizing. He said the beef stroganoff had so much grease on it that the entire plate had a layer of grease.
Resident #14 was interviewed on 1/23/24 at 4:20 p.m. Resident #14 said the meals were questionable. Resident #14 said she often received meals that were inedible.
Resident #77 was interviewed again on 1/24/24 at 3:49 p.m. Resident #77 said the food was awful. Resident #77 said the food was never fresh and always frozen.
Resident #83 was interviewed on 1/24/24 at 3:53 p.m. Resident #83 said the food was terrible. Resident #83 said breakfast was the only good meal.
IV. Record review and observations
The 10/12/23 food committee notes revealed the residents reported the biscuits and gravy was dry and needed extra gravy. The residents also reported the enchiladas and the macaroni and cheese looked bad and did not taste good.
The recipe for the beef stroganoff was provided by the nutrition services director (NSD) on 1/22/24 at 5:11 p.m. The recipe indicated onion, ground black pepper, ground beef, vegetable oil, beef soup base, water, canned cream of mushroom soup, sour cream and canned mushrooms and pieces were supposed to be in the beef stroganoff.
During a continuous observation on 1/22/24, beginning at 11:00 a.m. and ending at 12:45 p.m., the following was observed:
-At 11:57 a.m., the NSD was using a slotted spoodle to get the broccoli out of the liquid. The broccoli was brown. The broccoli that was served was in small pieces and appeared mushy;
-At 12:03 p.m., the NSD said they were out of broccoli and needed to make more and the NSD instructed the cook (CK) to put frozen broccoli into a pot with water;
-At 12:13 p.m., the NSD said the broccoli was at the correct temperature and poured the broccoli and cooking water into a container in the steam table that had liquid butter in it;
-At 12:25 p.m. the NSD said they ran out of egg noodles and beef stroganoff. The CK began cooking the egg noodles. The NSD began browning ground beef on the stove and put some white gravy mix and water on the stove. When the ground beef reached the correct temperature, the NSD poured the gravy mixture into the ground beef and stirred it together. The NSD poured the beef stroganoff into the steam table and started preparing resident plates again.
-The NSD did not follow the recipe for making the beef stroganoff.
V. Staff interviews
The NSD was interviewed on 1/22/24 at 4:40 p.m. The NSD said she was not aware of any food concerns.
The NSD said she was not sure why the beef stroganoff tasted like flour.
The CK was interviewed on 1/23/24 at 8:50 a.m. The CK said she worked as the health information specialist and occasionally as a cook. She said she did not follow the recipe for the beef stroganoff. She said the NSD told her to brown beef then add biscuits and gravy base and a little worcestershire sauce. The CK said the facility did not have any worcestershire sauce so she added soy sauce for a little color.
The CK said she did not use onions, mushrooms or sour cream in the beef stroganoff.
CNC #1 was interviewed on 1/23/24 at 6:03 p.m. CNC #1 said the cooks should follow the recipes to ensure the food was cooked correctly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected multiple residents
Based on observations, record review and interviews, the facility failed to provide food and beverages that accommodated resident preferences for five (#66, #79, #59, #14 and #83) of five residents re...
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Based on observations, record review and interviews, the facility failed to provide food and beverages that accommodated resident preferences for five (#66, #79, #59, #14 and #83) of five residents reviewed food and beverage preferences out of 52 sample residents.
Specifically, the facility failed to offer food choices to residents who preferred to eat in their room for Residents #66, #79, #59, #14 and #83.
I. Facility policy
The Resident Food Preferences policy, revised July 2017, was received from the corporate nurse consultant (CC) #1 on 1/23/24. It read in pertinent part: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent.
The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night.
II. Resident interviews
Resident #79 was interviewed on 1/17/24 at 10:41 a.m. Resident #79 said he preferred to eat in his room. Resident #79 said there was an alternative menu. Resident #79 said the alternative menu items were not offered to residents that ate in their rooms. Resident #79 said the staff brought him meals everyday, but did not offer him choices
Resident #66 was interviewed on 1/17/24 at 1:45 p.m. Resident #66 said he always ate his meals in his room. Resident #66 said the staff brought him meals but did not ask him what he wanted.
Resident #59 was interviewed on 1/23/24 at 12:41 p.m. Resident #59 said she preferred not to eat. Resident #59's meal ticket was on her bedside table and listed she did not like beef, chicken or pork. Resident #59 said she was often served food items that contained foods that she did not like. Resident #59 said she always ate meals in her room. Resident #59 said the staff brought her meals without asking what she wanted. Resident #59 said she was often brought food items she did not like.
Resident #14 was interviewed on 1/23/24 at 4:20 p.m. Resident #14 said she typically ate in her room. The resident said there used to be a staff member that came around to take dinner orders the night before and would do so usually four days a week. Resident #14 said orders had not been taken in a long time.
Resident #14 said if she did not like her meals, she would ask a certified nursing aide (CNA) to get her a peanut butter and jelly sandwich or a bowl of cereal. The resident said the alternatives to the meals provided on the dinner trays were usually soups or salads.
Resident #83 was interviewed on 1/24/24 at 3:53 p.m. Resident #83 said she always ate in her room. The resident said she was always served the same thing for breakfast and wanted to know how she could get a banana with her breakfast. Resident #83 said staff members used to come around and ask what residents wanted for dinner but had stopped doing so.
III. Record review
A grievance form, filled out on 12/13/23 by the activities director (AD) as a result from the December 2023 resident council meeting, documented the residents complained of orders not being taken for room trays. The grievance form indicated the complaint would be forwarded to the dietary department and the concierge would start taking room orders.
C. Staff interviews
CNA #3 was interviewed on 1/24/24 at 10:30 a.m. CNA #3 said the registered dietitian did the meal tickets for residents who ate in their rooms. CNA #3 said the CNAs at the facility only handed the trays to the residents.
The nutrition services director (NSD) was interviewed on 1/24/24 at 4:06 p.m. The NSD said meal preferences were assessed by the dining program at admission and checked every quarter. The NSD said a complaint was received two weeks prior regarding meal preferences. The NSD said the concierge and a CNA went around the facility to take orders. The NSD said the kitchen staff took food orders prior to this.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of two nourishment rooms.
Specifically, the facility f...
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Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of two nourishment rooms.
Specifically, the facility failed to:
-Ensure frozen nutritional supplements and thickened liquids were dated appropriately;
-Ensure timely cleaning of the ice machine;
-Ensure food was labeled and dated in the nourishment rooms;
-Ensure food was properly cooled; and,
-Ensure food was reheated appropriately.
Findings include:
I. Ensure frozen nutritional supplements and thickened liquids were dated appropriately
A. Professional reference
The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations,
https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, retrieved 1/29/24, read in pertinent part, Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.
B. Observations
On 1/17/24 at 8:51 a.m. in the main dining room there was a drink cart with an opened container of thickened juice. The thickened juice did not have an open date.
During the initial kitchen tour on 1/17/23 at 8:52 a.m. the following was observed:
-In the main walk-in refrigerator there was an opened container of thickened apple juice and an opened container of thickened orange juice with no opened date; and,
-There was a box of mighty shakes (frozen nutritional supplement) with no pull date.
During a continuous observation on 1/22/24, beginning at 11:00 a.m. and ending at 12:45 p.m., the following was observed:
-There was a metal container with mighty shakes on the service line with no pull date.
On 1/22/24 at 4:11 p.m. in the south side nourishment room refrigerator the following was observed:
-An opened container of nectar thick water and a container of nectar thick cranberry juice with no open date and a mighty shake with no pull date.
At 4:12 p.m. there was a drink cart on the south side hallway that had an opened container of nectar thick water with no open date.
At 4:16 p.m. in the north side nourishment room refrigerator the following was observed:
-An opened container of honey thick liquid with no opened date. The liquid was semi-solid.
C. Staff interviews
The nutrition services director (NSD) and the corporate registered dietitian (CRD) were interviewed on 1/22/24 at 4:40 p.m. The NSD said thickened liquids needed to be labeled with an opened date.
The CRD said thickened liquids needed to be disposed of 10 days after being opened. The CRD said mighty shakes needed to be labeled when they were pulled from the freezer. The CRD said mighty shakes were only good for 14 days after they were thawed.
The CRD said she would provide education to the staff on thickened liquids and mighty shakes.
The NDS said the staff typically wrote the pull date on the box that the mighty shakes were delivered in. The NSD said the mighty shakes should not be stored in the nourishment room refrigerators.
II. Ensure timely cleaning of the ice machine
A. Professional reference
The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved 1/29/24, read in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
B. Observations and record review
During the initial kitchen tour on 1/17/23 at 8:52 a.m. the following was observed:
-The ice machine had hard water stains on the sides of the machine; and,
-On the inside of the ice machine there was a brown and orange build-up where the ice was dispensed for resident use.
During a continuous observation on 1/22/24, beginning at 11:00 a.m. and ending at 12:45 p.m., the following was observed:
-The ice machine remained with water stains and the brown and orange build-up.
On 1/22/24 at approximately 4:50 p.m., the NSD looked into the ice machine and said it looked like there was rust in the ice machine and there were hard water stains on the outside of the machine.
A copy of the most recent cleaning of the ice machine was requested on 1/22/24. The NSD said she would have to contact the outside company for a copy of the receipt showing the machine was cleaned in October 2023.
-The NSD did not provide a copy of the receipt during the survey process.
C. Staff interviews
The NSD was interviewed on 1/22/24 at 4:50 p.m. The NSD said the ice machine needed to be cleaned.
The NSD said the machine was last professionally cleaned in October 2023. The NSD said an outside company cleaned the ice machine every six months. The NSD said the dining staff wiped off the outside of the ice machine, but dido not clean the inside of the machine.
III. Ensure food was labeled and dated in the nourishment rooms
A. Professional reference
The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved on 1/29/24, read in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request.
B. Facility policy and procedure
The Food from Outside Sources policy, revised 7/28/23, was provided by the clinical nurse consultant (CNC) #1 on 1/27/24 at 4:58 p.m. It read in pertinent part, Purpose: All foods may be permitted from outside sources if deemed safe and wholesome per state and federal guidelines and within medical advice.
If food is not consumed upon arrival, it may be stored in a suitable container and labeled with date, resident anime and item description if needed.
Suitable containers properly seal foods to prevent dryness or drainage. Examples of suitable containers are plastic with tight fitting lid, clamshells for restaurant leftovers and tight closing plastic storage bags.
Resident's food stored under refrigeration shall have name, date, and expiration date on the label.
Perishable food is discarded within three days from any resident refrigerator source unless the food item is safe until a printed expiration date.
C. Observations
On 1/22/24 at 4:11 p.m. in the south side nourishment room refrigerator the following was observed:
-A bag of sausages with no label or date
At 4:16 p.m. in the north side nourishment room refrigerator the following was observed:
-An opened container of yogurt with no open date;
-An opened can of Spam labeled 1/13/24; and,
-A peanut butter and jelly sandwich labeled 1/17.
D. Staff interviews
The NSD was interviewed on 1/22/24 at 4:40 p.m. The NSD said opened foods needed to be disposed of three days after being opened. The NSD said she was unsure where the bag of sausages came from and disposed of them. The NSD said the Spam, peanut butter and jelly sandwich and yogurt needed to be thrown away.
IV. Ensure food was properly cooled
A. Professional reference
The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, retrieved 1/29/24, read in pertinent part, Maintain the records required to confirm that cooling and cold holding refrigeration time/temperature parameters are required as part of the HACCP (hazard analysis critical control point) plan.
B. Facility policy and procedure
The HACCP (Hazardous Analysis and Critical Control Points) procedure, dated 2020, was provided by CNC #2 on 1/24/24 at 4:30 p.m. It read in pertinent part, Instructions: record temperatures every hour during the cooling cycle. Record corrective actions taken if applicable. The supervisor of food operation will verify proper cooling procedures by routinely monitoring work activity. Cooling guidelines, you must demonstrate that the temperature, has moved from 135? (fahrenheit) to 70? within 2 hours, has moved from 70? to 41? within the remaining 4 hours, if the temperature for the first 2 hours was not cooled to 70?, the temperature must be cooled completely through the danger zone (41?) in the next 2 hours. Any food not properly moved through the two-stage process and cooled to 41? must be discarded.
C. Observations
During the initial kitchen tour on 1/17/23 at 8:52 a.m. the following was observed:
-A container of cooked hard boiled eggs that were hot to the touch;
-A container of cooked soup with no label or date;
-A container of cooked sausage patties that were still hot; and,
-A container of cooked chicken tenders.
During a continuous observation on 1/22/24, beginning at 11:00 a.m. and ending at 12:45 p.m., the following was observed:
-A container of cooked soup;
-A container of cooked mechanical soft vegetables;
-A container of cooked pureed vegetables; and,
-A container of cooked beans.
D. Record review
On 1/24/24 at approximately 4:30 p.m. CNC #2 provided a copy of the cooling log.
-The cooling log was last utilized on 9/30/23.
E. Staff interviews
The NSD was interviewed on 1/22/24 at 4:40 p.m. The NSD said foods needed to be cooled properly and logged on the food cooling sheet.
The NSD said the food cooling monitor log had not been utilized since September 2023. The NSD said foods needed to be cooled properly to prevent bacteria growth.
V. Ensure food was reheated appropriately
A. Professional reference
The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved on 1/29/24,t read in pertinent part; The food shall have an initial temperature of 41ºF or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control.
Reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating.
B. Facility policy and procedure
The Food from Outside Sources policy, revised 7/28/23, was provided by CNC #1 on 1/27/24 at 4:58 p.m. It read in pertinent part, Food from a home source must be heated to 165 degrees for 15 seconds and served at 150 degrees or less. Food temperatures are recorded for service. Food may be cooled for several minutes to 150 degrees.
C. Observations
On 1/23/24 at 4:58 p.m. certified nursing assistant (CNA) #1 was walking down the hallway with a frozen lasagna. CNA #1 said she did not take the temperature of the lasagna. CNA #1 said the resident instructed her to cook the lasagna for eight minutes in the microwave. CNA #1 entered the resident's room and gave him the microwaved lasagna.
D. Record review and staff interviews
The NSD was interviewed on 1/23/24 at 5:00 p.m. The NSD entered the nourishment room and said there was a microwave for resident use. The NSD said the facility staff needed to microwave the item and take the temperature of the food. The NSD said the food needed to be heated to 165 degrees fahrenheit. The NSD said the staff needed to log the food item's temperature on the clipboard in the nourishment room. The NSD said the temperature log was not filled out and the lasagna was served to the resident prior to ensuring the food was at the correct temperature.
CNC #1 was interviewed on 1/23/24 at 6:03 p.m. CNC #1 said the resident told the facility staff that the lasagna was not warm enough and needed to be heated more.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observations and staff interviews, the facility failed to ensure garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects for two ...
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Based on observations and staff interviews, the facility failed to ensure garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects for two of three dumpster areas.
Specifically, the facility failed to ensure garbage and potentially hazardous medical waste was disposed of in the proper receptacles or dumpster.
Findings include:
I. Professional reference
The Colorado Department of Public Health and Environment (2019) the Colorado Retail Food Establishment Rules and Regulations,
https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved on 1/30/24, read in pertinent part, Receptacles and waste handling units for refuse, recyclables, and returnable used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.
Cardboard or other packaging material that does not contain food residues and that is awaiting regularly scheduled delivery to a recycling or disposal site may be stored outside without being in a covered receptacle if it is stored so that it does not create a rodent harborage problem.
II. Observations
On 1/22/24 at 12:44 p.m., the garbage dumpster could be observed from the common area, through a window, on the north unit. From the window, the dumpsters were towards the back of the parking lot. The dumpster on the right side was open and had trash bags overflowing from the top.
On 1/23/24 at 10:56 a.m., observation of the dumpster area in the north parking lot revealed the following:
-Trash, including gloves, empty bottles, cardboard and other items were on the ground near the dumpster;
-There were four grocery carts overflowing with trash near the dumpsters;
-The dumpster on the right near the canal did not have a lid; and,
-The dumpster on the left had a broken lid and the side door was open.
On 1/24/24 at 8:22 a.m., the dumpsters remained open and there was garbage on the ground surrounding the dumpsters.
III. Staff interviews
The maintenance director (MTD) was interviewed on 1/23/24 at 10:56 a.m. The MTD said the trash was picked up on Mondays, Wednesdays and Fridays. The MTD said there were homeless people that often got into the dumpsters and made it a mess. The MTD said he tried to keep the area clean, but there was nothing he could do regarding the mess the homeless people made. The MTD said the two dumpsters were used for all of the facility's trash.
The MTD said he was not aware the dumpster lids were not properly functioning. The MTD said he would call the dumpster company and have them replaced. The MTD said there were frequently pests, including racoons, getting into the dumpster. The MTD said the facility had not discussed moving the dumpsters or placing a fence around the dumpsters to help keep the area clean.
Clinical nurse consultant (CNC) #1 was interviewed on 1/23/24 at 2:47 p.m. CNC #1 said the facility frequently called the police because homeless people went through their dumpsters. She said the dumpsters should have lids on them. CNC #1 said she would ensure the dumpsters got new lids so they could be closed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently duri...
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Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.
Specifically, the facility failed to develop a facility assessment which included all resources, education, staff competencies and facility based risk assessments.
Findings include:
I. Facility policy and procedure
The Facility Assessment policy, dated October 2018, was provided by clinical nurse consultant (CNC) #1 on 1/27/24 at 4:58 p.m. It read in pertinent part, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment.
The facility assessment includes a detailed review of the resident population.
The facility assessment also includes a detailed review of the resources available to meet the needs of the resident population.
The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps determine budget, staffing, training, equipment and supplies needed. It is separate from the quality assurance and performance improvement evaluation.
II. Record review
The facility assessment was last reviewed in August 2023 by the previous nursing home administrator (NHA), the director of nursing (DON), the medical director and the governing body.
The facility assessment failed to:
-Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs are met for all new and existing staff;
-Include staff trainings/education necessary to provide the level and types of support and care needed for the resident population;
-Identify facility resources needed to provide competent resident support during day to day operations and emergencies; and,
-Include the facility-based and community-based risk assessment, utilizing an all-hazards approach.
III. Staff interviews
Corporate consultant (CC) #1 and CNC #1 were interviewed together on 1/24/24 at 12:25 p.m.
CC #1 said the previous NHA had reviewed the facility assessment a few months ago.
CC #1 and CNC #1 said the facility assessment needed to be more detailed.
CNC #1 said the facility assessment had several sections that included prompts but the prompts were not filled out to capture the needs of the facility.
CC #1 and CNC #1 reviewed the facility assessment and confirmed the assessment did not have specific training staff needed to help the residents at the facility.
CC #1 said the assessment did not include a facility-based risk hazard approach.
CC #1 said he would assist in ensuring the facility assessment was updated.
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 interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate...
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Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to infection control.
Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to infection control.
Findings include:
I. Facility policy
The Quality Management Plan policy, reviewed on 11/26/19, was received on 1/17/24 from the nursing home administrator (NHA). The policy read in pertinent part, on going quality management program designed to objectively and systematically monitor and evaluate the resident's care and health care services. The comprehensive program is designed to provide care that is optional within resources and is consistent twitch the achievable goals to ensure that monitoring of residents' care is performed systematically and continuously.
To identify the organizational components responsible for quality management program functions and to delineate the components which include the line of authority, responsibility, and accountability.
II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent deficiencies and initiate a plan to correct
F883 Immunizations
During the recertification survey on 1/24/24 immunizations was cited at an F scope and severity which was at widespread substandard care.
III. Staff interview
The medical director (MD) was interviewed on 1/23/24 at 3:40 p.m. The MD said he attended the QAPI meeting monthly. He said it was important for the providers to review the resident's immunization records.
The MD said residents should be re-offered the pneumococcal vaccination annually if they refused it initially.
The MD said that the facility has had turnover in leadership and it was hard to have consistency.
Corporate consultant (CC) #1 and corporate nurse consultant (CNC) #1 were interviewed on 1/24/24 at 5:19 p.m. CC #1 said the QAPI committee met monthly with the interdisciplinary team (IDT) and the medical director in attendance.
CC #1 said the meeting had an agenda. He said after the monthly meetings, they have sub-committees which meet to discuss root cause analysis.
The QAPI looked for trends and then root causes and then put a performance improvement plan in place.
CC #1 said the QAPI discussed immunizations which included, COVID-19, influenza and pneumococcal vaccinations. He said the medical director decided when the influenza vaccinations were to be administered.
CC #1 said in December 2023 the corporation had sent out an email in regards to vaccinations. The email was directing staff to review the pneumococcal vaccinations and ensure the residents were offered. However, unfortunately the blasted out email failed to include the current director of nurses and the nursing home administrator was too new and they were not on the email.
CC #1 said the medical director did provide education on the importance of vaccinations.
CC #1 said the failure was the alert which was sent out failed to reach the facility and therefore an audit was not completed on immunizations.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the p...
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Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases, including COVID-19, for 10 (#72, #26, #79, #24, #38, #4, #81, #52, #11, #17 and #56) of 10 residents reviewed for COVID-19 immunizations out of 52 sample residents.
Specifically, the facility failed to ensure tracking, offering and administration of the COVID-19 vaccination.
Findings include:
A. Facility policy and procedure
The Immunizations policy, reviewed 7/28/23, was provided by the clinical nurse consultant (CNC) #1 on 1/17/24 at approximately 11:00 a.m. It read in pertinent part, Purpose: To minimize the risk of residents acquiring, transmitting, or experiencing compilations for influenza, pneumococcal pneumonia, and COVID-19 by assuring that each resident is informed about the benefits and risks of immunizations and has the opportunity to be immunized unless medically contraindicated or if refused by the resident or their legal representative.
Before offering the influenza, pneumococcal, or COVID-19 immunization, each resident, or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunizations.
Each resident will be offered the COVID-19 immunization, unless immunization is medically contraindicated or they are up-to-date with the current vaccine.
The resident or the resident's representative has the opportunity to refuse immunizations; and the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of each of these immunizations. And that the resident either received the immunization(s) or did not receive them due to medical contraindications or refusal.
The facility will determine whether or not a resident has received the COVID-19 immunization at the time of admission to the facility.
If the resident is unsure if immunization(s) has been administered, the medical provider or medical director will be contacted to determine appropriateness of administration of immunization and documented in the medical record.
The facility will obtain a provider's order for all immunization(s).
The immunization will be administered per manufacturer's guidelines. The facility will document in the electronic health record the date, time and injection site for administration of each immunization. The information will be documented in the Immunization section of the EHR (electronic health record).
Historical immunization will be documented in the Immunization section of the EHR when the information is available.
Refusals of immunizations will be documented in the Immunization section of the EH with education provided to the resident or resident's representative.
B. Resident interviews
Resident #72 was interviewed on 1/17/24 at 2:04 p.m. She said she had not received the most recent COVID-19 vaccination. Resident #72 said she was immunocompromised and wanted to get the COVID-19 booster vaccination. Resident #72 said she was afraid to leave her room, as there was a COVID-19 outbreak in the facility.
Resident #26 was interviewed on 1/17/24 at 3:19 p.m. Resident #26 said she wanted to get the up-to-date COVID-19 vaccination. Resident #26 said she had requested multiple times to receive the vaccination and still had not received it.
Resident #79 was interviewed on 1/22/24 at 3:55 p.m. Resident #79 said he had not received the most recent COVID-19 vaccination and would like it.
C. Record review
According to the electronic medical records (EMR) of Residents #4, #52 and #56, the immunization records were not up to date with the residents' COVID-19 vaccination status.
According to the EMR, Residents #72, #26, #79, #24, #38, #4, #52, #11, #17 and #56 had not been offered a COVID-19 vaccination or offered an additional COVID-19 booster vaccination.
According to the EMR, Resident #56 did not have a documented declination form with risk versus benefit education for immunization.
D. Staff interviews
The infection preventionist (IP) and CNC #1 were interviewed together on 1/18/24 at 3:26 p.m. The IP said she had recently started her role.
The IP said they had ordered the updated COVID-19 vaccines but had not offered or administered it to residents yet.
CNC #1 said the COVID-19 vaccinations should be offered per the Center for Disease Control (CDC) recommendations. CNC #1 said the facility had not received the COVID-19 vaccines yet.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal and infl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal and influenza vaccinations for 11 (#72, #26, #79, #24, #38, #4, #81, #52, #11, #17 and #56) of 11 residents out of 52 sample residents.
Specifically, the facility failed to:
-Administer the pneumococcal vaccination after Resident #72, #79, #4 consented to the vaccination;
-Obtain a physician's order to administer the annual influenza vaccination for Resident #72, #26, #79, #24, #38, #4 and #11;
-Determine if additional doses of the pneumococcal vaccination were needed and offer the additional doses of the pneumococcal vaccination as needed to Resident #26, #24, #35, #52, #17, and #56;
-Document declination forms, document risk versus benefit education and re-offer the pneumococcal vaccination annually for Resident #81 and #11; and,
-Document risk versus benefit education for the influenza vaccination for Resident #81, #52 and #56.
Findings include:
I. Professional reference
According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2022, retrieved on 12/13/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part, Routine vaccination-pneumococcal-For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20). (see notes)
For those over the age of 65 who meet age requirements and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20.
Special situations: age [AGE]-64 years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups.
Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies.
Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies.
II. Facility policy and procedure
The Immunizations policy, reviewed 7/28/23, was provided by the corporate nurse consultant (CNC) #1 on 1/17/24 at approximately 11:00 a.m. It revealed in pertinent part, Purpose: To minimize the risk of residents acquiring, transmitting, or experiencing compilations for influenza, pneumococcal pneumonia, and COVID-19 by assuring that each resident is informed about the benefits and risks of immunizations and has the opportunity to be immunized unless medically contraindicated or if refused by the resident or their legal representative.
Before offering the influenza, pneumococcal, or COVID-19 immunization, each resident, or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunizations.
Each resident will be offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period.
The resident or the resident's representative has the opportunity to refuse immunizations; and the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of each of these immunizations. And that the resident either received the immunization(s) or did not receive them due to medical contraindications or refusal.
The facility will assess whether or not a resident has received the influenza vaccination at the time of admission to the facility and annually thereafter during the specified time frame (October 1 through March 31).
The facility will determine whether or not a resident has received a pneumococcal immunization at the time of admission to the facility and again after age [AGE] if the resident ages in place to turn 65.
If the resident is unsure if immunization(s) has been administered, the medical provider or medical director will be contacted to determine appropriateness of administration of immunization and documented in the medical record.
The facility will obtain a provider's order for all immunization(s).
The immunization will be administered per manufacturer's guidelines. The facility will document in the electronic health record the date, time and injection site for administration of each immunization. The information will be documented in the Immunization section of the EHR (electronic health record).
Historical immunization will be documented in the Immunization section of the EHR when the information is available.
Refusals of immunizations will be documented in the Immunization section of the EH with education provided to the resident or resident's representative.
III. Resident #72
A. Resident status
Resident #72, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included type two diabetes mellitus, obesity and hypertension (high blood pressure).
The 11/28/23 minimum data set (MDS) assessment revealed the resident was not offered the pneumococcal vaccine.
B. Record review
Resident #72 signed a consent form on 11/7/22 to receive the pneumococcal vaccination. Resident #72's EMR documented Resident #72 received the influenza vaccination on 11/2/23.
-A review of Resident #72's electronic medical record (EMR) revealed the resident had not received the pneumonia vaccination.
-However, there was no documentation that indicated Resident #72 had received the pneumococcal vaccination.
-A review of Resident #72's November 2023 medication administration record (MAR) did not reveal a physician order to receive the influenza vaccination.
IV. Resident #26
A. Resident status
Resident #26, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included heart failure, hypertension (high blood pressure) and anxiety.
The 10/18/23 MDS assessment revealed the resident was not up to date on her pneumococcal vaccination but did not indicate a reason.
B. Record review
A review of Resident #26's EMR immunization tab revealed the resident received the influenza vaccination on 11/2/23. A copy of the state immunization system uploaded into the resident's EMR revealed the resident received the Pneumovax and the Prevnar 23 on 12/8/2020.
-There was no documentation that indicated the resident had been offered the updated pneumococcal vaccination.
-A review of Resident #26's November 2023 MAR did not reveal a physician order to receive the influenza vaccination.
C. Resident interview
Resident #26 was interviewed on 1/17/24 at 3:19 p.m. Resident #26 said she wanted to get the up-to-date pneumococcal vaccination. Resident #26 said she had requested multiple times to receive the vaccination and still had not received it.
V. Resident #79
A. Resident status
Resident #79, under the age of 65, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included hypertension (high blood pressure), anxiety and alcohol abuse.
The 11/7/23 MDS indicated the resident had not been offered the pneumococcal vaccination.
B. Record review
A review of Resident #79's EMR immunization tab revealed the resident received the influenza vaccination on 11/2/23. A copy of the state immunization system uploaded into the resident's EMR revealed the resident had received the Prevnar 23 in 2020. The resident was offered and consented to receive the pneumococcal vaccination on 8/10/23.
-A review of the residents August and September 2023 MAR did not reveal the resident had received the pneumococcal vaccination.
-A review of Resident #79's November 2023 MAR did not reveal a physician order to receive the influenza vaccination.
C. Resident interview
Resident #79 was interviewed on 1/22/24 at 3:55 p.m. Resident #79 said he requested to have the pneumonia vaccination upon admission and had yet to receive it.
VI. Resident #24
A. Resident status
Resident #24, under the age of 65, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included depression and type one diabetes mellitus.
The 10/31/23 MDS assessment indicated Resident #24 was not up to date on her pneumococcal vaccination and did not provide a reason.
B. Record review
A review of Resident #24's EMR immunization tab revealed the resident received the influenza vaccination on 11/6/23 and the pneumovax on 2/4/16 and 5/1/21. A copy of the state immunization system uploaded into the resident's EMR revealed the resident received the Prevnar 23 on 2/4/16.
-The resident's medical record did not specify which pneumovax the resident received on 5/1/21.
-There was no documentation that indicated the resident had been offered the updated pneumococcal vaccination.
-A review of Resident #24's November 2023 MAR did not reveal a physician order to receive the influenza vaccination.
VII. Resident #38
A. Resident status
Resident #38, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 CPO, diagnoses included dementia, hypertension (high blood pressure) and anxiety.
The 12/8/23 MDS assessment indicated Resident #38 received the influenza vaccination on 12/8/23 and she was up to date on the pneumococcal vaccination.
B. Record review
A review of Resident #38's EMR immunization tab revealed the resident received the influenza vaccination on 11/8/23.
-The resident's EMR did not indicate if the resident had received any pneumococcal vaccinations.
-There was no documentation that indicated the resident had been offered a pneumococcal vaccination.
-A review of Resident #38's November 2023 MAR did not reveal a physician order to receive the influenza vaccination.
VIII. Resident #4
A. Resident status
Resident #4, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 CPO, diagnoses included diabetes mellitus, seizure disorder and anxiety.
The 12/8/23 MDS assessment indicated the resident received the influenza vaccination on 11/2/23 and was not up to date on the pneumococcal vaccination but did not indicate a reason.
B. Record review
A review of Resident #4's EMR immunization tab revealed the resident received the influenza vacation on 11/2/23 and the Prevnar 13 on 12/22/16. The resident consented to receive the pneumococcal vaccination on 6/22/22.
-There was no documentation that indicated the resident had been administered the pneumococcal vaccination after consenting on 6/22/22.
-A review of Resident #4's November 2023 MAR did not reveal a physician order to receive the influenza vaccination.
IX. Resident #81
A. Resident status
Resident #81, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included chronic myeloid leukemia (cancer of the blood).
The 11/2/23 MDS assessment indicated the resident was offered the influenza vaccine and declined. The MDS assessment indicated the resident was not up to date on the pneumococcal vaccination and did not state a reason why.
B. Record review
A review of Resident #81's EMR revealed the resident refused the influenza vaccination but did not provide a date of refusal.
-There was no documentation that the resident had been offered or received the pneumococcal vaccination.
On 1/22/24 at 3:45 p.m. CNC #1 provided a copy of the pneumococcal and influenza declination form for Resident #81. It revealed the resident was offered the pneumococcal vaccination on 1/21/24 and refused (during the survey process).
-The declination form did not include a reason why the resident refused.
-The influenza vaccination declination form did not indicate why the resident refused. The resident was provided education regarding the risk versus benefits of the influenza vaccination on 1/19/24 (during the survey process).
X. Resident #52
A. Resident status
Resident #52, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 CPO, diagnoses included diabetes mellitus and depression.
The 11/16/23 MDS indicated the resident was offered and declined the influenza vaccination and was not offered the pneumococcal vaccination.
B. Record review
A review of Resident #52's EMR revealed the resident refused the influenza vaccination but did not provide a date of refusal.
-There was no documentation that the resident had been offered or received the pneumococcal vaccination
On 1/22/24 at 3:45 p.m. CNC #1 provided a copy of the influenza declination form. The form was signed by one licensed nurse and said the resident refused and did not state a reason why.
The resident was provided education regarding the risk versus benefits of the influenza vaccination on 1/19/24 (during the survey process).
XI. Resident #11
A. Resident status
Resident #11, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 CPO, diagnoses included vascular dementia, anxiety and epilepsy (seizure disorder).
The 11/7/23 MDS assessment indicated the resident received the influenza vaccination on 11/2/23. The MDS assessment indicated the resident was not up to date on the pneumococcal vaccination but did not state a reason.
B. Record review
A review of Resident #11's EMR revealed the resident received the influenza vaccination on 11/2/23. The resident's EMR revealed he received the pneumovax on 7/18/11 and the Prevnar 13 on 3/22/17.
The resident declined the pneumococcal vaccination on 11/16/18.
-The declination form did not provide a reason or risk versus benefit education.
-There was no documentation that revealed the resident had been reoffered the pneumococcal vaccination annually.
On 1/22/24 at 3:45 p.m. CNC #1 provided a copy of the pneumococcal consent form that indicated the resident consented to receive the pneumococcal vaccination on 1/20/24 (during the survey process).
-A review of Resident #11's November 2023 MAR did not reveal a physician order to receive the influenza vaccination.
XII. Resident #17
A. Resident status
Resident #17, age [AGE] years old, was admitted on [DATE] and remitted on 12/26/23. According to the January 2024 CPO, diagnoses included multiple myeloma (cancer), end stage renal disease (kidney failure) and obesity.
The 1/1/24 MDS assessment indicated the resident had received the influenza vaccination outside the facility and was up to date on the pneumococcal vaccination.
B. Record review
A review of Resident #17's EMR revealed the resident received the influenza vaccination on 9/28/23 and 11/10/23.
-The EMR did not reveal documentation that the resident had received or been offered the pneumococcal vaccination.
On 1/22/24 at 3:45 p.m. CNC #1 provided a copy of the pneumococcal immunization form. Resident #17 consented to receive the pneumococcal vaccination on 1/19/24 (during the survey process).
XIII. Resident #56
A. Resident status
Resident #56, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 CPO, diagnoses included type two diabetes mellitus and vascular dementia.
The 12/20/23 MDS assessment indicated the resident was offered and refused the influenza vaccination. The MDS assessment indicated the resident was not offered the pneumococcal vaccination.
B. Record review
A review of Resident #56's EMR revealed the resident refused the influenza vaccination but did not provide a date.
-There was no documentation in the resident's EMR that indicated she had been offered or given the pneumococcal vaccination.
On 1/22/24 at 3:45 p.m. CNC #1 provided a copy of the 11/2/23 influenza declination form. The resident was provided risk versus benefit education on 1/19/24 (during the survey process).
XIV. Staff interviews
The infection preventionist (IP) and CNC #1 were interviewed on 1/18/24 at 3:26 p.m. The IP said she had recently started her role.
The IP said when a resident was admitted to the facility she reviewed the hospital discharge paperwork to determine which immunization(s) the resident had received and which immunizations they needed. The IP said she did not have access to the state immunization system, so she would ask the hospital liaison to access it for her if needed.
CNC #1 said the facility recently started a new process that they were working on rolling out. CNC #1 said the process would include an assessment that would document which immunizations the resident had received historically and help assist the facility in determining which immunizations the resident needed to be offered.
CNC #1 said the assessment could then be utilized to pull reports annually to determine which residents needed to be offered or re-offered vaccinations.
CNC #1 said the facility needed to obtain physician orders if the facility administered the influenza vaccinations.
The IP said the facility administered the influenza vaccinations.
CNC #1 and the IP acknowledged the facility did not obtain physician orders for the influenza vaccinations for Resident #72, # 26, #79, #24, #38, #4 and #11.
CNC #1 said the residents should be offered the influenza vaccination annually. CNC #1 said if the resident refused the influenza vaccination a declination form should be filled out and risk versus benefit education completed with the resident.
CNC #1 said if a resident refused the pneumococcal vaccination a declination form should be filled out that included risk versus benefit education and the resident should be re-offered the pneumonia vaccination annually.
The IP said Resident #81, Resident #52 and Resident #56 were not provided risk versus benefit education upon refusal of the influenza vaccination.
The IP and CNC #1 said they followed the Centers for Disease Control (CDC) guidance for offering the pneumococcal vaccination.
The IP said the facility utilized the immunization tab in the EMR to track the immunizations for each resident. The IP said all historical, current and refusal of immunizations should be documented under the immunization tab.
CNC #1 said the 2023 influenza vaccination consents were not uploaded into the resident's EMR as they should have been.
CNC #1 said Resident #79 had not received the pneumococcal vaccination after consenting to receive it.
The medical director was interviewed on 1/23/24 at 3:40 p.m. The medical director said the facility needed to look up what immunizations each resident had been administered historically and offer needed vaccinations.
The medical director said residents should be re-offered the pneumococcal vaccination annually if they refused it initially.
Jul 2023
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect and keep safe from abuse and neglect two (#1 and #3) resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect and keep safe from abuse and neglect two (#1 and #3) residents out of six sample residents.
On 6/12/23 the facility failed to send an escort to a medical appointment outside of the facility with Resident #1 who had cognitive impairment, Parkinson's Disease and autism. The facility had evaluated Resident #1 was unsafe to go out of the building by herself three different times (11/7/22, 1/22/23, and 4/18/23) prior to the appointment on 6/12/23. Resident #1 was dropped off at a medical office building by herself, and was found wandering down a hallway not in the physician's waiting area by the medical office personnel. The medical personnel called the facility to come and help Resident #1. A facility staff person who answered the phone responded that they would see what they could do but they (the facility) could not promise anything. The medical personnel at the physician's office then called the corporation who owned the facility. The corporation made phone calls to get a van driver to come pick up Resident #1 and return her to the facility. The medical appointment building was on a busy street which posed a potential threat had Resident #1 not been found and had she wandered out of the building. It took approximately one and a half hours from the time Resident #1 was dropped off at the medical building until she was returned to the facility.
The facility's appointment scheduler for the residents was not a clinical medical staff member, and said he based his evaluations of the resident's safety on his own observations. Even though Resident #1 had documentation of the need for an escort for her safety, the appointment scheduler said he did not read the evaluations, or consult with the facility's nursing staff to determine the resident's needs for an escort when out in the community.
The former nursing home administrator (FNHA) knew of the situation on 6/12/23 and did not put interventions in place to prevent the incident from occurring again. The facility did not put interventions in place to make sure residents who needed escorts had that provision until a survey began in the building 10 days later on 6/22/23.
The facility failed to provide Resident #1 the escort and supervision necessary while out in the community at a medical appointment, which created the likelihood of serious harm or injury if not immediately corrected for Resident #1.
In addition, the facility failed to protect Resident #3 from physical abuse from Resident #4 who pulled Resident #3's hair out of her head. Resident #4 said she would continue physical violence on Resident #3 under certain conditions. The facility did not investigate the incident thoroughly and implement interventions for the two residents or take action for the safety of other residents in the facility.
Findings include:
I. Immediate jeopardy
A. Findings of immediate jeopardy
On 6/12/23 the facility failed to send an escort to a medical appointment outside of the facility with Resident #1 who had cognitive impairment, Parkinson's Disease and autism. The resident had been evaluated to have an escort when she went anywhere out into the community. The resident was dropped off at a medical appointment in the community, left on her own with no escort and she was not taken to the area where her appointment was located by the van driver. The resident was found wandering down a hallway in a medical office by the medical office staff. The medical office was close to a busy street. The facility failed to provide Resident #1 the escort and supervision necessary while out in the community at a medical appointment, which created the likelihood of serious harm or injury if not immediately corrected for Resident #1.
B. Facility notice of immediate jeopardy
On 7/18/23 at 1:31 p.m. the regional director of operations (RDO) and the new NHA were notified that the failures to ensure the safety of residents who needed escorts being transported outside of the facility, placed residents at risk for of serious harm.
C. Plan to remove immediate jeopardy
On 7/18/23 at 3:08 p.m the RDO and NHA presented the following plan to address the immediate jeopardy situation, which read in part:
On 6/22/23 (a) facility wide review was done to ensure transport will be provided (with) all information regarding what the needs of the resident are and if an escort is needed to ensure the safety of the resident during transport and appointment.
On 6/22/23 when (the) facility NHA was suspended then eventually terminated, (the) facility staff was notified that they were to notify the RDO and/or QI (Quality Improvement person) of any and all community emergency (ies) involving residents until facility hired a full time NHA.
On 6/13/22 in the a.m. the organization sent out a community wide email to address this concern. Specifically, (corporate name) shared with all communities:
When an emergency occurs with (a) resident or escort during transport and/or appointment (the) escort is to call the NHA/DON (director of nursing) to deploy help to escort and/or resident. Escorts will have (a) cell phone to reach (the) facility if needed.
4. On 6/22/23 (name of facility scheduler for outside appointments) was removed from the appointment process, facility nursing team replaced (name) in appointment process, this was done to ensure adequate clinical evaluation would be completed.
5. The facility implemented a system for scheduling, arranging transportation, and assessing the type of transport needed (wheelchair/stretcher).
a. Upon admission, orders are reviewed for appointments, following admission residents or nurses notify a nurse or member of the nurse management team of appointment, nurse or member of the nurse management team will input information into (the name of the electronic medical record system) under clinical communications. IDT (interdisciplinary team) and nurse managers will assess for (the) required type of transport, and if an escort is required.
b. Nursing will evaluate (a) resident upon changes of condition to ensure a safe appointment and needs are met during appointment and transport.
c. Nurse assesses for (the) required type of transport and if an escort is required.
d. Centralized driving provided additional education related to resident drop off/pick up with van drivers on 6/26/23.
e. On 6/29/23 centralized driver did additional training with the three unit managers specifically related to date, the time, the address, phone number, patient's mobility and if an escort is required.
All scheduled appointments will be reviewed in (the) morning meeting to ensure that proper preparation is completed.
f. The appointment is scheduled.
g. A nurse has determined the type of transport that is required and if an escort is required.
h. Transportation is arranged.
i. Any orders that are required (prep, preop, labs, holding of meds) are implemented.
j. Equipment that is required for transport is available and ready and checked the day prior to transport.
All incidents or issues identified with a transport will be reviewed by the clinical team and supervisor and reviewed using the QAPI (quality assurance and performance improvement) process.
D. Removal of immediate jeopardy
On 7/18/23 at 3:13 p.m. the NHA and RDO were notified the immediate jeopardy was lifted based on evidence of the facility's implementation of the above plan. However, deficient practice remained at a D scope, isolated with a potential for more than minimal harm.
E. Facility follow up
The RDO was interviewed on 7/18/23 at 4:10 p.m. The RDO said after his investigation into the incident with Resident #1 the company decided the former NHA, DON and the social service assistant (SSA) were no longer employees at the facility. The RDO said the SSA was the one who answered the phone when the medical office personnel called to notify the facility that Resident #1 was unescorted. He said the facility staff person who scheduled appointments for the residents outside of the facility in the community was no longer the facility scheduler. He said when the state survey began in his building last month he and the quality improvement (QI) looked into incidents that had happened in the facility. He said on 6/22/23 it was discovered what had happened with Resident #1 and he began interventions immediately to fix the situation for all of the residents.
II. Facility policy and procedure
The Abuse policy, revised 5/3/23, was provided by the nursing home administrator (NHA) on 6/21/23 at 12:05 p.m. It revealed in pertinent part,
Communities do (sic) not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents.
Residents have the right to be free from abuse, neglect.
Standards
1. Providing a safe environment for the resident is one of the most basic and essential duties of our facility.
2. Employees have a unique position of trust with vulnerable residents.
3. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents.
4. Identification of abuse shall be the responsibility of every employee.
Physical abuse is defined as abuse that results in physical harm with intent. It includes hitting, slapping, pinching, kicking.
Common area is expanded to recognize the inclusion of living rooms or other similar areas where residents gather.
Neglect is the failure of the facility, its employees or service provider to provide goods, and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress.
Facility will take action when identifying events such as suspicious bruising or skin tears. Occurrences, patterns and trends that may constitute abuse will be identified and appropriate action taken.
In addition to an investigation by the Police Department, the facility conducts an internal investigation. While the investigation is ongoing, the alleged assailant has interventions implemented to help ensure the safety of the alleged victim as well as other residents. The investigation includes interviewing any staff members, residents, or family members who may have knowledge of the incident.
Abuse By Other Residents
If a resident experiences a behavior change resulting in aggression toward other residents, the community will implement interventions for protection of the alleged assailant and other residents. The facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening.
III. Resident #1
A. Resident status
Resident #1, age under 70, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), the diagnoses included paranoid schizophrenia, bipolar disorder, autism, pseudobulbar affect (uncontrollable laughing or crying), secondary Parkinsonism, anxiety disorder, gastro-esophageal reflux disease (GERD), other chronic pain and an overactive bladder.
The 4/18/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She required supervision with bed mobility, dressing, toilet use and personal hygiene. She was occasionally incontinent of urine.
B. Record review
The independent outing pass evaluations for Resident #1 revealed the following:
-On 11/7/22 it was not recommended for Resident #1 to have independent passes at this time due to her mental and physical disabilities.
-On 1/22/23 due to Resident #1's cognitive deficits it was not recommended that she have an independent pass.
-On 4/18/23 due to Resident #1's cognitive status it was not recommended to go out independently.
The comprehensive care plan, initiated 11/2/22 and revised on 5/16/23, revealed the resident had a communication problem with autistic disorder.
-Interventions (for) communication (were to) allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off (the) television/radio to reduce environmental noise. Ask yes/no questions if appropriate. Use simple/brief consistent words/cues. Use alternative communication tools as needed.
-Remind and escort Resident #1 to activities in the facility, and (remind and escort) to outings in the community.
-The 4/19/23 nursing care plan revealed it was recommended that Resident #1 have supervised passes due to her cognitive status. The goal was Resident #1 would be safe and comfortable during therapeutic outings. Social services (staff) and the interdisciplinary team (IDT) would work in concert with the resident and family/friends to provide maximum wellbeing for the resident.
C. Interview with the hospital case worker (HCW)
The HCW (where Resident #1 went to her medical appointment) was interviewed on 6/21/23 at 8:19 a.m. She said Resident #1 was dropped off at the hospital for a medical appointment and was found wandering around the hospital all alone. She said she called the facility to come and help Resident #1. She was told by a facility staff person they would see what they could do, and they could not promise anything. She said the resident had Parkinson's disease and dementia. She said the resident should not be left alone with her conditions. She said the hospital did not have the resources to provide a caretaker for her. She said the medical center for the appointment was on a very busy street. She said it would not be safe if Resident #1 had wandered out of the building because of the busy street. She said the hospital staff found Resident #1, who had wandered down a hallway, not by her appointment place. She said she told the facility that the resident could not return to the hospital for an appointment until they called the hospital to communicate that a caregiver would be sent in the future. She said as of 6/21/23 no staff from the facility called the medical office to let them know that in the future the facility would send a caregiver with Resident #1 for her medical appointments.
D. Family interview and Resident #1 observation with attempted interview
The legal guardian and sister of Resident #1 was interviewed on 6/21/23 at 11:00 a.m. She said she tried as often as she could to attend medical appointments with her sister. She said on 6/12/23 she forgot about the scheduled appointment and did not go to the doctor's visit to meet her sister. She said her sister was unable to attend anything outside of the facility without an escort due to her physical and mental disabilities. She said her sister often got agitated. She said when people asked Resident #1 a question she often just responded with no, because she was unable to communicate with a conversation.
Resident #1 was observed and an interview was attempted on 6/26/23 at 12:30 p.m. She continually swayed her torso back and forth from seated upright to bent over her knees. She said she liked her hamburger. She was unable to answer any other questions.
E. Staff interviews
The social service (SS) person was interviewed on 6/21/21 at 4:34 p.m. She said Resident #1 went into the community to a doctor's appointment on 6/12/23. She said the company van with a driver brought her to the appointment. She said Resident #1 did not have a caregiver or any escort with her for her appointment. She said Resident #1 should have had an escort the entire time when leaving the facility to go to her medical appointment. She said she thought Resident #1 was found at the medical office an hour after she was dropped off. She said she did not know which day she informed the resident's sister of the event but she said she thought it was later in the same week as the incident. She said if she could find documentation of the phone call to notify the sister who was the legal guardian she would provide the date.
-No documentation was provided by exit on 6/26/23.
The central transport scheduler (CTS) was interviewed on 6/22/23 at 12:30 p.m. He said one of the drivers took Resident #1 to her medical appointment and another driver picked her up and returned her to the facility. He said his team was not informed that Resident #1 needed an escort. He said the person who scheduled medical appointments with the corporate van drivers would put on the driver's calendars that a resident needed an escort. He said he was going to have a meeting with the van drivers on Monday 6/26/23 to discuss residents who needed escorts into the community. He said he did not know why the meeting would happen two weeks after the event but he would get it handled with his team.
The transportation driver assistant (TDA) was interviewed on 6/22/23 at 12:47 p.m. He said he did not know that Resident #1 was to have an escort when he took her to her medical appointment on 6/12/23. He said he had forms that were to tell the drivers if someone needed an escort. He said no escort was listed for Resident #1. He said he brought Resident #1 to the front inside of the medical building but he did not stay with her because he was not told to do so.
The medical records director was interviewed on 6/22/23 at 12:31 p.m. He said he was the person responsible for all transport scheduling in the facility for the residents. He said he wrote down on a centralized calendar for the van drivers what resident needed the appointment, where the appointment was located, what time the appointment was and what doctor the resident was to visit. He said he was the one responsible to determine the qualifications if a person needed a caregiver or escort to a medical appointment. He said he did not work with nursing or the director of nursing to determine who needed an escort. He said he walked around the facility and he could tell by a resident's behavior if they needed an escort to a medical appointment or not. He said he may look in the medical records to see if a resident had dementia and needed an escort. He said he made the decision about escorts and no other staff made the decision in the facility. He said he decided if a resident needed a certified nurse aide (CNA). He said if he saw a resident with behaviors in the facility he would send an escort. He said it had been some time since someone in the facility went out with an escort. He said Resident #1 did not go out with an escort on 6/12/23.
CNA #1 was interviewed on 6/22/23 at 2:42 p.m. She said at the nurses station there was a list of residents who had appointments each day and at what time the appointment was scheduled. She said the CNAs got the residents ready and brought them to the front of the facility to meet the van driver. She said she had not gone to any appointments with Resident #1. She said Resident #1 needed daily guidance in the facility to do all of her daily care.
CNA #2 was interviewed on 6/22/23 at 2:45 p.m. She said she worked with Resident #1. She said Resident #1 needed prompting to do all of her daily cares. She said Resident #1 had to be helped to take a shower because she could not cognitively take a shower on her own.
F. Facility follow-up
The regional director of operations (RDO) and corporate consultant (CC) were interviewed on 6/22/23 at 11:45 a.m. The RDO and CC said that as of today 6/22/23 the facility began a plan to make sure residents who needed escorts out into the community would have that service provided. They said previous management in the facility had not fixed the situation after the incident happened with Resident #1. The RDO and CC provided documentation of the plan to fix the situation that had happened with Resident #1 (10 days later). The plan included the following in pertinent part:
-Interventions - The facility would implement a system for scheduling, arranging transportation, and assessing the type of transportation needed. Nurses (would) assess (the) required type of transportation and if an escort was necessary. All scheduled appointments would be reviewed in the morning meeting to ensure that proper preparation was completed.
IV. Resident to resident physical abuse between Resident #4 and Resident #3
A. Incident on 5/22/23
The facility had used 5/22/23 and 5/23/23 interchangeably for when the event occurred.
On 5/22/23 Resident #4 and Resident #3 were in a common area waiting to go outside with staff for a supervised smoking break. Resident #4 grabbed Resident #3 by her hair and pulled it out of her head.
-The facility did not do a complete investigation after the incident and did not implement any measures for Resident #4, Resident#3, nor did the facility implement any safety measures for the other residents in the facility (cross-reference F610).
In an interview with Resident #4 during the survey she said she would be aggressive again at Resident #3 if needed (see below).
On 6/21/23 (during survey) the facility RDO and CC began an investigation into the incident, conducted interviews and began to put interventions into place for the residents.
The CC provided a company email of a conversation on 6/6/23 from the corporate social services quality mentor to the NHA. (During the survey, the NHA was suspended). On 6/6/23 (12 days after the incident) the NHA was given a list of suggestions and ideas to put interventions into place for Resident #4. The interventions were ideas to help with increased behaviors and how to implement and help the resident.
The CC said on 6/26/23 at 2:36 p.m., that the NHA had instructions of what to do for Resident #4 (provided in the email above), but he did not do what was asked of him to do.
The RDO and CC during survey on 6/22/23 began an investigation into the physical abuse between Resident #4 and Resident #3, which included interviewing residents and staff and putting interventions into place (see facility follow-up below).
B. Resident #4
1. Resident status (assailant)
Resident #4, age under 70, was admitted on [DATE]. According to the June 2023 CPO, the diagnoses included bipolar disorder, anxiety disorder, borderline personality disorder, nicotine dependence, alcohol abuse and unspecified dementia.
The 6/8/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive assistance with bed mobility, transfers, dressing, personal hygiene and toilet use. She required limited assistance with locomotion off the unit. She self propelled in a wheelchair. She did not reject care from staff.
2. Record review
The behavior comprehensive care plan, initiated 10/25/19 and revised on 5/23/23, revealed:
Focus: Resident had a history of bipolar disorder, borderline personality disorder, and dementia with behavioral disturbances. She could be verbally and physically aggressive towards staff. She received pleasure out of getting a reaction out of others often in a negative way. History of false accusations which regarded staff and residents. Resident #4 had become more aggressive to staff and other residents by cursing, throwing water/coffee, (and) pulling hair.
Goal: Will not cause harm to self or others, will not have aggression through review date. (9/2/23)
Interventions: Educate Resident #4 on appropriate boundaries. Encourage her not to involve herself in other residents' concerns. Offer cigarettes when she is out, to help with escalation in behaviors. Nursing facility staff should provide ongoing evaluation and documentation of moods, participation in care, treatment, medication management, and psychiatric stability.
On 5/4/21 Resident #4 was documented as a supervised smoker.
The 5/23/23 nursing progress note revealed Resident #4 pulled out Resident #3's hair yesterday, placed on frequent checks, informed staff to keep her away from the south station unless it was designated smoking times.
The May 2023 behaviors treatment administration record (TAR) revealed:
-The behavior tracking question was: did the resident have a behavior directed at another resident? It was documented that the resident had no behaviors directed towards others on 5/23/23 and 5/30/23.
-However, Resident #4 did have behaviors directed at other residents on 5/23/23 and 5/30/23.
Dietary progress notes on 5/30/23 revealed Resident #4 and her tablemate at lunch yelled at each other. Resident #4 threw milk at the other resident.
Incident progress notes on 6/3/23 revealed Resident #4 threw food on another resident during breakfast. She was educated to treat others as she would like to be treated and Resident #4 said she did not care.
3. Resident interview
Resident #4 was interviewed on 6/22/23 at 2:45 p.m. She said she pulled Resident #3's hair because she was a (expletive). She said because she pulled her hair and dumped oatmeal on another resident, she was being punished by the NHA. She said she agreed to wear a patch to help her not smoke for now. She said she planned on smoking in the future. She said for now she agreed to not smoke because of hurting Resident #3.
Resident #4 was interviewed again on 6/26/23 at 1:35 p.m. She said she could propel herself in her wheelchair in the facility. She said the CNAs helped to put her in bed and helped her out of bed. She said it was up to her and Resident #3 to get along with each other. She said Resident #3 sat by the bird cages and she passed her from her room while going to the dining room. She said if Resident #3 talked to her in a way she did not like she would, Hit her and plug her right in the nose. She said that she was currently not smoking but she planned to start up again on 7/4/23.
4. Staff interviews
Registered nurse (RN) #1 was interviewed on 6/22/23 at 2:40 p.m. She said Resident #4 quit smoking. She said because Resident #4 quit smoking there would be no more incidents between Resident #3 and Resident #4.
CNA #1 was interviewed on 6/26/23 at 3:00 p.m. She said she had seen Resident #4 kick other residents. She said Resident #4 used bad words at others often.
RN #2 was interviewed on 6/26/23 at 3:05 p.m. She said Resident #4 was verbally aggressive to her. She said Resident #4 could really cuss staff and residents out. She said Resident #4 was very difficult to redirect at times.
CNA #2 was interviewed on 6/26/23 at 3:10 p.m. She said Resident #4 was very verbally and physically aggressive to staff and other residents. She said when CNAs witnessed Resident #4 being verbally aggressive at another resident, the CNAs moved her wheelchair to try and move her away from others before something bad happened. She said when the CNAs put Resident #4 to bed they knew that she could not be aggressive to any other residents because she needed help to get out of bed. She said the only time CNAs knew others were safe was when Resident #4 was in bed.
C. Resident #3
1. Resident #3 (victim)
Resident #3, age under 70, was admitted on [DATE]. According to the June 2023 CPO, the diagnoses included hemiplegia (stroke), schizoaffective disorder, chronic pulmonary obstructive disease (COPD), depressive disorder, psychoactive substance abuse, depression, vascular dementia, seizures and a traumatic brain injury (TBI).
The 5/30/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. She had unclear speech. She sometimes was able to understand others. She required extensive assistance with bed mobility, transfers, personal hygiene, dressing and toilet use. She was independent with locomotion on and off the unit. She did not reject care from staff.
2. Record review
On 5/12/22 Resident #3 was documented as a supervised smoker.
The comprehensive care plan, initiated 8/12/22 and revised on 6/19/23, revealed the following for behaviors:
Focus: Resident #3 will call out loudly when upset, and has the potential to disturb other residents when she calls out loudly.
Interventions: Assist to develop more appropriate methods of coping and interacting. Encourage her to express her feelings appropriately. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior was inappropriate and/or unacceptable to the resident. Monitor behavior episodes and attempt to determine (the) underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.
The 2/6/23 nurse practitioner (NP) note revealed Resident #3 was difficult to assess due to expressive aphasia (loss of ability to understand or express speech) but able to make her needs known with yes or no answers to questions.
The 5/22/23 administrative progress note documented Resident #3 had a large piece of hair ripped out by Resident #4, (an) abuse investigation (was) started.
The 6/5/23 social service assessment documented the resident was unable to speak.
3. Resident and representative interview and resident observation
The legal guardian (LG) of Resident #3 was interviewed on 6/26/23 at 11:00 a.m. She said she was assigned as the legal guardian for Resident #3 and she visited with Resident #3 one time per month. She said she did not remember what exact day she was contacted about the hair pulling incident but the facility did call her. She said she told the facility social worker that if the police came in to interview Resident #3 that she (the LG) must be present with the resident. She said Resident #3 could not communicate well. She said because the facility never called her back she assumed the police never came to the facility to investigate the situation. She said she was never told why the facility did not stop the situation in the first place.
Resident #3 was observed on 6/26/23 at 1:00 p.m. She was seated in the common area watching the birds in the birdcage. The common area was located where Resident #4 would need to pass by to get to her room. Resident #3 was unable to communicate by way of a conversation. When asked if her hair was pulled out, she responded yes.
D. Staff interviews
RN #1 was interviewed on 6/22/23 at 2:40 p.m. She said the altercation between Resident #3 and Resident #4 happened in the common area as residents waited to go out and smoke. She said Resident #3 was to be supervised while she was smoking in the smoking area. She said Resident #3 would propel herself throughout the building unsupervised. She said Resident #4 quit smoking so there should be no more incidents between the two women as long as Resident #4 did not smoke.
The RDO was interviewed on 6/26/23 at 2:21 p.m. He said the former NHA did not handle the situation and follow the directions from the corporate social service clinical resource person. He said the NHA was suspended during the survey. He said during the survey on 6/21/23 an investigation was completed. He said on 6/21/23 all staff and residents were interviewed about physical and verbal abuse. He said Resident #4 had been interviewed. He said Resident #3 (the victim) was not interviewed because she was nonverbal. He said he felt both women were wanting to smoke and possibly staff was late to get the smokers outside. He said he felt that may be what agitated the women. He said he understood that the victim should be interviewed and he would make sure Resident #3 would be interviewed. He said he did not know if a physician or psychiatric care was provided for Resident #3 after the incident.
E. Facility follow-up
On 6/26/23 at 2:20 p.m. the RDO and CC gave documentation to show that on 6/21/23 the facility began interviews and an investigation of the 5/23/23 resident to resident physical abuse between Resident #3 and Resident #4. The documentation contained the following:
Occurrence date and time 5/23[TRUNCATED]
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility failed to timely investigate allegations of physical abuse for two (#4 and #3) residents out of six sample residents.
Specifically, the facility fai...
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Based on record review and interviews, the facility failed to timely investigate allegations of physical abuse for two (#4 and #3) residents out of six sample residents.
Specifically, the facility failed to investigate resident to resident physical abuse. Resident #4 pulled hair out of Resident #3's head. The facility did not investigate and put interventions in place for the residents involved in the situation, as well as for the safety of all of the residents in the facility.
Findings include:
I. Facility policy and procedure
The Abuse policy, revised 5/3/23, was provided by the nursing home administrator (NHA) on 6/21/23 at 12:05 p.m. It revealed in pertinent part,
Communities do (sic) not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents.
Residents have the right to be free from abuse.
Standards
Providing a safe environment for the resident is one of the most basic and essential duties of our facility.
Facility will take action when identifying events such as suspicious bruising or skin tears. Occurrences, patterns and trends that may constitute abuse will be identified and appropriate action taken.
In addition to an investigation by the Police Department, the facility conducts an internal investigation. While the investigation is ongoing, the alleged assailant has interventions implemented to help ensure the safety of the alleged victim as well as other residents. The investigation includes interviewing any staff members, residents, or family members who may have knowledge of the incident.
Abuse By Other Residents
If a resident experiences a behavior change resulting in aggression toward other residents, the community will implement interventions for protection of the alleged assailant and other residents. The facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening.
II. Resident to resident physical abuse between Resident #4 and Resident #3
The facility had used 5/22/23 and 5/23/23 interchangeably for when the event occurred.
On 5/22/23 Resident #4 and Resident #3 were in a common area waiting to go outside with staff for a supervised smoking break. Resident #4 grabbed Resident #3 by her hair and pulled it out of her head. The facility did not do a complete investigation after the incident and did not implement any measures for Resident #4, Resident#3, nor did the facility implement any safety measures for the other residents in the facility (cross-reference F600 for abuse). On 6/21/23 (during survey) the facility's regional director of operations (RDO) and the corporate consultant (CC) began an investigation into the incident, conducted interviews and began to put interventions into place for the residents.
The CC provided a company email of a conversation on 6/6/23 from the corporate social services quality mentor to the NHA. (During the survey the NHA was suspended). On 6/6/23 (12 days after the incident) the NHA was given a list of suggestions, and ideas to put interventions into place. The interventions were ideas to help with increased behaviors and how to implement and help after the physical abuse occurred.
The CC said on 6/26/23 at 2:36 p.m., the NHA had instructions of what to do, but he did not do what was asked of him to do.
The RDO and CC during survey began an investigation into the physical abuse between Resident #4 and Resident #3, which included interviewing residents and staff, and putting interventions into place (see facility follow-up below).
III. Staff interviews
The RDO was interviewed on 6/26/23 at 2:21 p.m. He said the former NHA did not handle the situation and follow the directions from the corporate social service clinical resource person. He said the NHA was suspended during the survey. He said during the survey last week an investigation was begun. He said on 6/21/23 all staff and residents were interviewed about physical and verbal abuse. He said Resident #4 had been interviewed. He said Resident #3 (the victim) was not interviewed because she was non-verbal. He said he felt both women were wanting to smoke and possibly staff was late to get the smokers outside. He said he felt that may be what agitated the women. He said he understood that the victim should be interviewed and he would make sure Resident #3 would be interviewed. He said he did not know if a physician or psychiatric care was provided for Resident #3 after the incident.
The CC was interviewed on 6/26/23 at 2:21 p.m. She said when the survey began on 6/21/23 she looked into the State Agency reporting portal and saw that the incident was entered by the NHA on 5/23/23 but the investigation was not completed. She said because of that she and the RDO had begun the investigation. She said the company had a document to use to interview those who were non-interviewable residents like Resident #3. She said the document worked when it was used but in this situation it was not utilized. She said Resident #3 would be interviewed during their investigation.
IV. Facility follow-up
On 6/26/23 at 2:20 p.m. the RDO and CC gave documentation to show that on 6/21/23 the facility began interviews and an investigation of the 5/23/23 resident to resident physical abuse between Resident #3 and Resident #4. The documentation contained the following,
Occurrence date and time 5/23/23 (time was not listed). Resident #4 peddled backwards in her wheelchair in hallway, bumped into Resident #3. Resident #4 ripped a large piece of hair out of Resident #3. Resident #4 had hair in her hand. No injury other than missing hair. 'Victim is non interviewable.'
Action plan: 6/21/23 It was identified that the facility did not complete a thorough investigation for recent allegations of abuse. Specifically, the (suspended) NHA did not ensure that resident interviews were conducted with residents, potential witnesses or staff. On 6/21/23 facility interviews were conducted of interviewable residents to identify any resident concerns about abuse. Staff were educated on reporting all allegations of abuse. The resident interviews were provided on 6/21/23 which documented that Resident #3 was not interviewed again.
The RDO said he would fix the situation and make sure to include the victim, Resident #3 in the investigation.
Sept 2022
14 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the necessary care and treatment to prevent ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the necessary care and treatment to prevent the development of pressure injuries for one (#74) of two residents reviewed of 39 sample residents.
Resident #74 was admitted to the facility on [DATE] with diagnoses of pressure ulcer of sacral region stage four, spinal stenosis (narrowing of spine), dementia, and chronic pain syndrome. The resident was admitted with hospice care and was followed by the wound physician. The resident was admitted with one stage 4 pressure ulcer to her sacrum. On 3/29/22 the resident developed a stage 2 pressure ulcer to her right lateral knee. On 4/19/22 the right lateral knee wound had developed to a stage 4 and a stage 2 pressure ulcer to the right scapula had developed. On 5/17/22 the right scapula wound had developed to a stage 4. On 5/31/22 an unstageable pressure ulcer to the right ischium was noted. Interventions to address the wound included dietary supplements, repositioning, weekly wound care, and an air mattress. The resident stated she was not repositioned frequently and there were no documented refusals of repositioning. Dietary interventions included Mighty Shakes and Ensure (nutrition supplements) with no additional interventions trialed as the resident's wounds continued to deteriorate (cross-reference F692 for nutritional parameters). A new alternating air mattress was provided in May following the development of the three additional wounds. The wound physician stated the wounds were unavoidable should the facility be repositioning the resident frequently and providing additional protein.
Findings include:
I. Professional reference
According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 10/3/22, Pressure ulcer classification is as follows:
Category/Stage 1: Nonblanchable Erythema
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate ' at risk ' individuals (a heralding sign of risk).
Category/Stage 2: Partial Thickness Skin Loss
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury.
Category/Stage 3: Full Thickness Skin Loss
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.
Category/Stage 4: Full Thickness Tissue Loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
Unstageable: Depth Unknown
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as ' the body's natural (biological) cover ' and should not be removed.
Suspected Deep Tissue Injury: Depth Unknown
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.
II. Facility policy
The Pressure Injury Prevention policy and procedure, revised 7/22/2020, was provided by the director of clinical services on 9/29/22 at 5:00 p.m. It read in pertinent part, A pressure injury can occur wherever pressure has impaired circulation to the tissue. Critical steps in pressure injury prevention and healing include: identifying the individual resident at risk for developing pressure injuries, identifying and evaluating the risk factors and changes in the resident's medical condition, identifying and evaluating factors can be removed or modified, implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors, monitoring the impact of interventions, and modifying the interventions as appropriate. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. The first step in prevention is the identification of the resident at risk for developing pressure injuries and the resident with existing pressure injury areas of skin that are at risk for breakdown. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of those interventions.
III. Resident #74
A. Resident status
Resident #74, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included pressure ulcer of sacral region stage four, spinal stenosis (narrowing of spine), dementia, and chronic pain syndrome.
The 9/26/22 minimum data set (MDS) assessment indicated the resident had a mild cognitive impairment with a brief interview of mental status score of 12 out of 15. It indicated the resident required extensive, two person assistance for bed mobility and transfers. It indicated the resident was at risk for pressure ulcers and had three stage 4 pressure ulcers with one of those three present at admission and one unstageable pressure ulcer that was not present at admission. It indicated skin and ulcer treatments were pressure relieving devices for her chair and bed, a turning and repositioning program, nutrition and hydration interventions, pressure ulcer care, and applications of ointments and medications.
B. Resident interview
An attempt to interview Resident #74 was made on 9/26/22 at 3:27 p.m. The resident said she was overwhelmed and did not want to answer questions at that time or the following day. She said she was in pain and requested a nurse come to check on her.
Resident #74 was interviewed on 9/28/22 at 3:05 p.m. She said she had pain associated with her wounds. She said repositioning helped the pain but the repositioning should be completed every four hours and staff were repositioning every six hours. She said she liked to have her pillows a specific way and staff would not always place the pillows in the way she requested. The resident then became upset and said she did not want to answer any additional questions.
Resident #74 was interviewed again on 9/28/22 at 4:45 p.m. She said her preferred position was on her back but she could tolerate being positioned on her sides. She said she was unable to reposition on her own.
C. Observations
On 9/28/22 at 9:55 a.m., Resident #74 was observed in her room. Certified nurse aide (CNA) #1 was in the room and seen taking the resident's vitals. Resident #74 was on her back with her heels on a pillow. CNA #1 assisted with moving the resident further up in the bed though Resident #74 remained on her back.
On 9/28/22 at 11:25 a.m., Resident #74 was observed in her room, positioned on her back. Her lunch tray was brought in and the resident remained positioned on her back while waiting for meal assistance.
On 9/28/22 at 2:00 p.m., Resident #74 was observed in her room in bed. She was on her back with a pillow below her heels.
On 9/29/22 at 8:35 a.m., Resident #74 was observed positioned on her right side with pillows under her left side. At 8:36 a.m., CNA #1 was observed entering the room to provide care. At 8:42 a.m., CNA #1 left the room and Resident #74 was observed positioned on her back.
D. Wound observations
On 9/28/22 at 10:25 a.m., wound care was provided for Resident #74. The assistant director of nursing (ADON), licensed practical nurse (LPN) #2, and CNA #3 were present for wound care. The sacrum and right scapula wounds were cleansed and dressings were changed. During the repositioning of the resident, a chapstick was observed under her right shoulder blade and LPN #2 removed it and an indent in the resident's skin was observed. The scapula dressing was saturated with serosanguinous (blood and serum) drainage that seeped through the dressing and onto the draw sheet of the bed. The wound bed appeared clean and gray in color. The sacral wound appeared beefy red and moist. Both wounds were cleansed and new dressings were applied.
On 9/29/22 at 1:45 p.m., wound care was provided for Resident #74. The ADON, LPN #3, and CNA #3 were present for wound care. The right ischium and right knee wounds were cleansed and dressings were changed. The right ischial wound had yellow slough in the wound bed and a moderate amount of serous drainage. The area was cleansed and appeared to have yellow slough post cleansing. A new dressing was applied. The right knee wound had yellow slough and was weeping serous fluid. After the area was cleaned the wound bed had 50% slough and 50% pink tissue. A new dressing was applied.
E. Record review
Resident #74 was initially seen by the wound physician on 11/22/21, shortly after she was admitted to the facility. The notes indicated the resident had one wound, a sacral stage 4 pressure ulcer. The wound was debrided during the encounter and post debridement measurements were 5.2 cm by 6 cm with a depth of 0.5 cm.
On 3/29/22 a nursing pressure injury initial and weekly monitoring note was completed. It indicated a facility acquired stage 3 right lateral knee pressure ulcer with an onset date of 3/28/22. The measurements were 1.5 cm by 1.4 cm with a depth of 0.2 cm.
On 4/5/22 the wound physician's notes addressed the right lateral knee pressure ulcer. The note indicated the wound was a stage 3 and measurements were 1.1 cm by 1.2 cm with a depth of 0.2 cm. The wound bed had 100% granulation.
On 4/19/22 a nursing pressure injury initial and weekly monitoring note was completed. It indicated a facility acquired stage 2 pressure ulcer to right lateral back with an onset date of 4/19/22. The measurements were 1.4 cm by 1.7 cm with a depth of 0 cm.
On 4/19/22 the wound physician's notes indicated the right lateral knee pressure ulcer changed from a stage 3 to a stage 4. The measurements were 1.6 cm by 0.7 cm with a depth of 0.4 cm. The wound bed had 20% slough and 80% granulation. The note indicated an additional pressure ulcer to the right scapula that was a stage 2. The measurements were 1.5 cm by 1.9 cm with no measurable depth. The wound bed had 100% epithelialization.
On 5/17/22 the wound physician's notes indicated the right scapula pressure ulcer was now at a stage 4. The measurements were 3.2 cm by 3.1 cm with a depth of 0.4 cm. It indicated a mild odor with 40% epithelialization and 60% slough. It indicated the wound was deteriorating. The note indicated the stage 4 sacral wound had no changes and the stage 4 right lateral wound was improving.
On 5/31/22 a nursing pressure injury initial and weekly monitoring note was completed. It indicated a facility acquired, unstageable pressure ulcer with an onset date of 5/31/22. The measurements were 4.0 cm by 1.5 cm with a depth of 0 cm. Additional wound documentation from this date indicated a new alternating pressure mattress was in place and functioning.
On 6/7/22 the wound physician's notes indicated a right ischial unstageable pressure ulcer. The measurements were 3.4 cm by 1.5 cm with no measurable depth. It indicated the wound bed had 100% eschar. The note indicated the stage 4 sacral wound was improving, the stage 4 right scapula wound was improving, and the stage 4 right lateral knee wound was deteriorating.
On 9/20/22 the most recent wound physician's notes indicated the stage 4 sacral wound had measurements of 3.7 cm by 5 cm and a depth of 0.1 cm. It indicated 10% slough and 90% granulation. It indicated no changes in wound progression. The stage 4 right lateral knee wound had measurements of 1 cm by 1 cm with a depth of 0.1 cm. It indicated 100% epithelialization. It indicated the wound was improving. The stage 4 right scapula wound had measurements of 4 cm by 2.5 cm with a depth of 0.2 cm. It indicated 15% slough and 85% granulation. It indicated there were no changes in the wound progression. The unstageable right ischial wound had measurements of 1.5 cm by 1.2 cm with a depth of 0.4 cm. It indicated 50% slough and 50% granulation. It indicated the wound was deteriorating.
The September CPO revealed the following:
-Mighty Shake with meals for supplement, ordered 11/6/21;
-Ensure Plus two times a day to promote wound healing, ordered 1/4/22;
-Monitor sacral wound area and document evaluation on the daily wound monitoring progress note every shift, ordered 1/27/22;
-Monitor right lateral knee stage 4 pressure ulcer and document evaluation on the daily wond monitoring progress note every evening shift every other day, ordered 4/20/22;
-Monitor right scapula stage 4 pressure ulcer and document evaluation on the daily wound monitoring progress note in the morning, ordered 5/18/22;
-Monitor right ischial unstageable pressure ulcer and document evaluation on the daily wound monitoring progress note every shift, ordered 6/15/22;
-For right scapula, cleanse wound with dakins solution, pat dry, protect periwound tissue with skin prep, sprinkle crushed flagyl and apply alginate to wound bed, and cover with dry dressing every day shift for wound care, ordered 6/22/22;
-For sacrum, cleanse wound with dakins solution, pat dry, protect periwound tissue with skin prep, sprinkle crushed flagyl and apply alginate to wound bed, and cover with dry dressing every shift for wound care, ordered 6/22/22;
-For right ischium, cleanse area with dakins solution, pat dry, protect periwound tissue with skin prep, sprinkle crushed flagyl and apply alginate to wound bed, and cover with dry dressing every day shift for wound care, ordered 6/28/22,
-Check to ensure air mattress is plugged in, powered on, and functioning properly every shift for imparied skin integrity, ordered 8/12/22;
-For right lateral knee, cleanse wound with dakins solution, pat dry, protect periwound with skin prep, apply honeygel to wound bed, and cover with dry dressing every other day shift for wound care, ordered 9/20/22.
The skin care plan, revised 8/1/22, indicated Resident #74 was admitted to the facility on hospice care with a stage 4 pressure ulcer with osteomyelitis to the sacral area. It indicated her wounds were unavoidable due refusal of repositioning and decreased oral intake. It indicated a stage 4 pressure ulcer to the right lateral knee was first observed on 3/28/22, a stage 4 pressure ulcer to the right scapula was first observed on 4/14/22, and an unstageable pressure ulcer to the right ischium was first observed on 5/17/22. Interventions included avoidance of positioning the resident on her right side as tolerated, education with the resident on causes of skin breakdown such as good nutrition and frequent repositioning, determining why resident refused treatment and trying alternative methods to gain compliance, weekly visits with wound physician, and use of pressure relieving mattress.
-However, the facility was unable to provide documentation that indicated the resident refused repositioning.
The activities of daily living care plan, revised 4/1/22, indicated Resident #74 had a self care performance deficit related to impaired mobility, weakness, and end of life care. Interventions included encouraging and assisting the resident to turn and reposition every two hours and staff assistance of one to two people for bed mobility.
-However, review of bed mobility task documentation from CNAs from April 2022 to September 2022 indicated bed mobility was offered every shift and on average documented to have occurred for three out of the four shifts.
F. Staff interviews
LPN #1 was interviewed on 9/28/22 at 2:20 p.m. She said Resident #74's initial wound was doing better and she had weekly visits with the wound physician. She said the resident did not refuse repositioning or treatments. She said the resident liked to have her pillows in a specific position and could be particular about that. She said the resident was on hospice care and so comfort was important.
The ADON was interviewed on 9/28/22 at 4:09 p.m. She said she was the wound nurse and rounded with the wound physician every Tuesday. She said worked with the registered dietitian to address skin concerns, completed weekly assessments and documentation, and educated the nurses on how to change dressings. She said Resident #74 was admitted with a stage 4 sacral pressure ulcer. She said the wound had improved since admission. She said the right knee pressure ulcer was a stage 3 on 3/28/22 and developed to a stage 4 on 4/19/22. She said the right scapula pressure ulcer was stage 2 on 4/3/22 and developed to a stage 4 on 5/17/22. She said the pressure ulcer to the ischium had always been unstageable. She said the pressure ulcers were on the right side because the resident had a preference to position on her right side. She said staff would encourage her to position on her left side but the resident refused. She said the resident had an air mattress since admission and a new one was purchased around April or May due to the increase in wounds. She said the resident had poor intake which could impact wound development and healing. She said the resident received Mighty Shakes as a supplement since admission and Ensures were added in January. She said she was unsure if any other interventions were added. She said the wounds were getting smaller and were kept clean.
The wound physician was interviewed on 9/28/22 at 4:25 p.m. He said the resident was admitted to the facility with a wound to her sacrum about a year ago. He said she had four wounds at his last encounter with her. He said the wounds were unavoidable since she had the preventative measure of repositioning and, from what he had been told, the facility was repositioning frequently. He said he provided education to the resident about the importance of repositioning and had told the facility to document everything such as refusals related to repositioning. He said all the wounds were doing great and the right ischium and right knee were almost healed. He said the resident should be on a liquid protein to further help with wound healing. He said since the wounds were improving, he believed the resident was receiving the interventions that were necessary.
CNA #2 was interviewed on 9/29/22 at 11:25 a.m. She said Resident #74 refused to be repositioned and she would try to encourage her. She said the resident did not say that it was painful to be repositioned, she just assumed the resident liked to be positioned in a way to look out the window.
CNA #1 was interviewed on 9/29/22 at 11:38 a.m. He said he did not regularly go into Resident #74's room to reposition but today he did. He said he did not typically go in every two or four hours. He said Resident #74 could not reposition independently and was very particular about her positioning. He said when he provided care to her, he would leave her in her preferred position which was on her back. He said today was the first time in a while she was positioned on her side.
The registered dietitian (RD) was interviewed on 9/29/22 at 2:20 p.m. She said Resident #74 was on a regular diet with regular texture and thin liquids. She said the resident had weight loss since admission and had wounds. She said the resident preferred to have her meals in bed and she did not know the resident's preferred foods. She said the resident consumed about 50% of her meals and comfort was the goal for the resident. She said the resident received Ensures twice a day and Mighty Shakes three times a day as supplements. She said the resident used to receive liquid protein but did not like it and refused. She said other options were discussed with the resident such as fortified foods, Boost supplements, or Ensure Clear and the resident was not interested. She said once the resident began to develop additional pressure ulcers and lose weight, these interventions were not offered again due to the previous conversations with the resident.
-The interventions that were discussed with the resident and refused were not documented (cross-reference F692).
The director of nursing (DON) was interviewed on 9/29/22 at 4:33 p.m. She said she did not have a lot of involvement in Resident #74's wounds as the wound nurse handled this area. She said repositioning expectations depended on the resident and what other interventions were in place. She said Resident #74 often refused to be repositioned so her air mattress was the best intervention. She said she would expect staff to continue to go offer repositioning to the resident and document refusals. She said Resident #74's care was also discussed at the nutrition at risk meetings and different supplements had been offered. She said the resident refused dietary interventions that could have aided in wound healing or prevention.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#74) of three out of 39 sample residents received the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#74) of three out of 39 sample residents received the care and services necessary to meet their nutritional needs and to maintain their highest level of physical well being.
Resident #74 was admitted to the facility on [DATE]. Diagnoses included pressure ulcer of sacral region stage four, gastro-esophageal reflux, dementia, and chronic pain syndrome. The resident was admitted with one stage 4 pressure ulcer to her sacrum and later developed three additional pressure ulcers. Dietary interventions included Mighty Shakes and Ensure Plus (nutritional supplements) with no additional interventions trialed as the resident's wounds continued to deteriorate (cross-reference F686 for pressure injuries).
In August 2022, a 34.2 pound weight loss was noted with a reweight requested to verify weight loss. The 9/13/22 and 9/28/22 weights indicated the resident had a 25.2 pounds (lbs) weight loss over six months, which was 22.7% considered significant. No additional dietary interventions were added due to previous resident refusals of other supplements. No documentation of education or discussions with the resident regarding other supplements were provided. Even though the resident was admitted to hospice care since admission, the resident was not offered any additional nutritional interventions when she had significant weight loss and with the development of the facility acquired pressure injuries.
Findings include:
I. Facility policy
The Weight Management policy, revised 1/17/2020, was provided by the director of clinical services on 9/29/22 at 5:45 p.m. It read in pertinent part, Residents are monitored (per physician orders) for significant weight change on a regular basis. Results are reviewed and analyzed by the facility for intervention as appropriate. Residents identified with significant weight change will be assessed by the IDT (interdisciplinary) team; and further interventions will be implemented to minimize the risk for further weight change where possible and promote weight stability. Residents with weight variance (loss or gain) are reweighed. Residents identified at risk for weight change will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, RD (registered dietitian) evaluation, assisted dining etc.
II. Resident status
Resident #74, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included pressure ulcer of sacral region stage four, gastro-esophageal reflux, dementia and chronic pain syndrome.
The 9/26/22 minimum data set (MDS) assessment indicated the resident had a mild cognitive impairment with a brief interview of mental status score of 12 out of 15. It indicated the resident required one person assistance for eating. It indicated the resident did not have a swallowing disorder. It did not indicate the resident's latest weight and the areas related to weight loss or weight gain were incomplete. No dental abnormalities were noted. It indicated the resident had skin and ulcer treatments that included nutrition and hydration interventions. It indicated the resident received hospice care.
III. Record review
Weights since admission revealed the following:
-On 12/4/21 the resident weighed 104.6 pounds;
-On 12/29/21 the resident weighed 108.0 pounds;
-On 2/22/22 the resident weighed 108.8 pounds;
-On 3/22/22 the resident weighed 109.4 pounds;
-On 4/26/22 the resident weighed 109.8 pounds;
-On 5/24/22 the resident weighed 110.8 pounds;
-On 6/21/22 the resident weighed 110.8 pounds;
-On 7/19/22 the resident weighed 110.8 pounds;
-On 8/9/22 the resident weighed 118.8 pounds;
-On 8/23/22 the resident weighed 84.4 pounds; a 34.4 lbs weight loss in two weeks;
-On 9/13/22 the resident weighed 84.4 pounds;
-On 9/28/22 the resident weighed 85.6 pounds; a 25.2 lb weight loss over six months, 22.7% weight loss considered significant.
The nutrition care plan, revised 3/9/22, indicated Resident #74 had a nutritional problem related to declining health status secondary to numerous comorbidities, hospice care, skin breakdown, bi polar disorder, personality disorder, and dementia. All interventions in the care plan had initiation dates of November to December 2021. Interventions included following the resident in the nutrition and skin team, obtaining preferences and offer as able, providing and serving supplements as ordered, and providing and serving diet as ordered and monitor intake and record every meal.
-The care plan did not indicate any revisions following the development of multiple pressure ulcers and resident's weight loss. Per staff interview (see below) the resident required assistance with eating, which was not indicated on her care plan.
The September 2022 CPO revealed the following:
-Mighty Shake with meals for supplement, ordered 11/6/21;
-Weekly weights every Tuesday day shift for weight monitoring, ordered 12/9/21;
-Ensure Plus two times a day to promote wound healing, ordered 1/4/22.
The initial nutritional assessment was completed on 11/19/21. It indicated Resident #74 was on a regular diet with regular texture and thin liquids. It noted the resident had 4 ounce Mightyshakes three times a day and 30 milliliters of liquid protein twice a day. It indicated the resident had a dislike of undercooked red beef and an allergy to scallops. The resident had her own teeth and vision and hearing were adequate. It noted the resident was on hospice care and remained in bed and was unable to be weighed. It noted intakes were 50-75% for breakfast and dinner and 25-50% for lunch. It indicated the amount of assistance needed with meals was variable. Risks of altered nutrition were identified as decreased appetite, self-feeding difficulty, pressure ulcers, and dementia. Estimated caloric needs were 1500-1750 calories and 65-75 grams of protein based on ideal body weight. No ideal body weight was indicated on the assessment. The most recent weight was 143 pounds from September 2021, while the resident was in the hospital.
A quarterly nutritional assessment was completed on 2/8/22. It indicated Resident #74 was on a regular diet with regular texture and thin liquids. It noted the resident had orders for Mighty shakes three times a day and Ensure Plus twice a day. It indicated intakes were 75-100% for breakfast and lunch and 50-75% for dinner. Current body weight was 108 pounds with a November 2021 weight of 104 pounds. It indicated to continue with the current care plan.
A nutritional reassessment was completed on 3/29/22 and indicated it was completed due to a change of condition. It indicated the resident continued on a regular diet with regular texture and thin liquids. It noted the resident had orders for four ounce Mighty Shakes three times a day and eight ounce Ensure Plus twice a day. It indicated the resident disliked undercooked beef and liked well done beef. No other food preferences were listed. It noted the resident's weight 30 days ago was 108.8 pounds. No other weight was listed. Intakes for breakfast and dinner were 25% and lunch was 25-50%. The assessment indicated the resident's weight increased slightly and she was followed by the nutrition and skin team for her wound on her sacrum and new wound on knee. It indicated her body mass index was 20.1 and within a desirable range. It indicated staff was assisting with dining. It noted weight loss, potential for wound decline, and potential for further skin breakdown was likely and expected due to physical condition.
A quarterly nutritional assessment was completed on 6/16/22. It indicated the resident continued on a regular diet with regular texture and thin liquids. It indicated the resident continued on Mighty Shakes three times a day and Ensure Plus twice a day. Meal intakes were noted at 75-100% for all meals. Current body weight was 110.8 pounds which indicated a 7.2% increase since December 2021. The assessment indicated the resident had wounds on her knee, back, and coccyx and to continue on current supplements for wound healing.
On 8/26/22 a weight change note was completed. It indicated the resident was followed by nutrition for skin concerns related to wounds on her sacrum, knee, scapula, and ischium. It indicated her weight was 84.4 pounds which was down from 118.8 pounds. It indicated a request for a reweight to verify accuracy as the weight was down 34.4 pounds in two weeks. It indicated to continue with Mightyshakes and Ensure Plus to increase calories and protein for wound healing.
On 8/31/22 a physician progress note was completed that indicated the resident was eating well. It indicated her weight continued to drop and was on comfort care. Her weight was noted as 84.4 pounds.
A quarterly nutritional assessment was completed on 9/5/22. It indicated the resident continued on a regular diet with regular texture and thin liquids. It indicated the resident continued on Mighty Shakes three times a day and Ensure Plus twice a day. It did not indicate a current body weight. It indicated on 8/23/22 the resident weighed 84.4 pounds. It indicated on 3/29/22 the resident weighed 109.8 pounds which was a 23.13% weight loss over the past 180 days.
-The assessment indicated no follow up weights had occurred in order to verify weight loss. No updates to the care plan were indicated.
On 9/6/22 a weight change note was completed. It indicated the resident was followed by nutrition for skin concerns related to wounds on her sacrum, knee, scapula, and ischium. It indicated a weight for the week was not available and the last weight was 84.4 pounds which was down from 118.8 pounds. It indicated a reweight was requested to verify weight loss but resident often stayed in bed. It indicated to continue with a regular diet with Mightyshakes at meals and Ensure Plus twice a day.
On 9/16/22 a physician progress note indicated the resident was frail but eating well. It indicated her weight was 84.4 pounds.
The meal and supplement intake records from August to September 2022 revealed the following:
-The resident typically consumed 26-75% of breakfast, lunch and dinner.
-The resident typically consumed 50-100% of Mighty Shake with meals.
-The resident was provided with Ensure Plus twice daily but there was no documentation of intake percentages.
IV. Interviews
Certified nurse aide (CNA) #2 was interviewed on 9/29/22 at 11:25 a.m. She said Resident #74 required assistance with eating. She said occasionally the resident could use her own hands to self feed. She said for breakfast that day the resident ate 75% of her meal.
CNA #1 was interviewed on 9/29/22 at 11:38 p.m. He said the resident required one-on-one assistance for eating. He said she would occasionally refuse food and he would offer an alternative and made sure she was given an Ensure.
The registered dietitian (RD) was interviewed on 9/29/22 at 2:20 p.m. She said Resident #74 had weight gain and weight loss since admitting in December 2021. The RD said the resident went up in weight since admission and then in August 2022 had two weights that were 84 pounds. She said these weights were on the Hoyer (mechanical lift) scale while the other weights had been obtained on wheelchair scale. She said the latest weight, 9/28/22, was obtained using the wheelchair scale and was 85.6 pounds which indicated a weight loss. She said over the last six months the resident had lost 24 pounds which was a 22% weight loss. She said she questioned the accuracy of the weight that was recorded around 118 pounds. She said the resident was on a regular diet, regular texture, and thin liquids. She said the resident was on liquid protein, for a time, for wound healing and supplement but did not like it so it was discontinued. She said this was around the spring when the resident had an increase in wounds. She said she discussed other options, such as Boost or fortified foods, with the resident, but the resident declined. She said there should be documentation of these refusals and discussions. She said the resident had an allergy to scallops and disliked undercooked beef but did not know her preferred foods. She said no additional interventions were provided following the weight loss observed on 8/26/22 due to the resident's previous refusals to try other supplements.
-The facility was unable to provide documentation of discussions of alternative supplements, resident refusals and additional dietary preferences with the significant weight loss.
The director of nursing (DON) was interviewed on 9/29/22 at 4:33 p.m. She said Resident #74 was discussed at length during nutrition at risk meetings. She said alternative options for supplements were offered and educated on but residents refused. She said this information should be documented. She said some of the discrepancy in weights may have been due to Hoyer scale needing to be recalibrated and this was only recently brought to her attention.
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** II. Resident #339
A. Resident status
Resident #339, younger than 65, was admitted on [DATE]. According to the September 2022 com...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Resident #339
A. Resident status
Resident #339, younger than 65, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included inclusion body myositis hypothyroidism (abnormal thyroid function), pulmonary hypertension, rheumatoid arthritis, and dementia with behavioral disturbances.
The 9/15/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. She required supervision with bed mobility and personal hygiene and was independent with transfers, walking, and dressing.
B. Resident interview and observations
Resident #339 was interviewed on 9/26/22 at 4:25 p.m. She said the facility staff always left her walker across the room. She said she needed her walker close by to be able to get to the restroom promptly. She said she needed the walker to be able to get up out of bed.
The resident's walker was observed folded up and stored across the room, behind the door.
On 9/27/22 10:30 a.m. Resident #339's walker was observed across the room next to the closet. It was not within reach of the resident.
C. Record review
The activities of daily living (ADL), revised 9/19/22, documented the resident had a self-care performance deficit related to muscle weakness and cognitive impairment. It indicated Resident #339 required the use of a walker to ambulate.
D. Staff interviews
Certified nurse aide (CNA) #4 was interviewed on 9/29/22 at 10:06 a.m. She said Resident #339 was independent with getting out of bed, ambulation and toileting with the use of her walker. She said the resident needed the walker to be within reach for her to be independent and safe.
The director of nursing (DON) and the director of clinical services (DCS) were interviewed on 9/29/22 at 4:22 p.m. The DON said if a resident was independent with their walker it should be kept within reach of the resident. She said Resident #339 used her walker to get up out of bed, ambulate and use the restroom. She said the resident's walker should be kept within reach to ensure the resident remained independent and did not ambulate without an assistive device.
Based on observations, record review, and interviews, the facility failed to ensure two (#440 and #339) of two residents reviewed received services in the facility with reasonable accommodation of resident's needs of 39 sample residents.
Specifically, the facility failed to ensure:
-Resident #440's room was set up so the resident was able to access items such as her call light, nightstand and bedside table, have access to her television remote and orient the resident on how to work her television, which was her preferred activity (cross-reference F679); and,
-Resident #339 had access to her walker which provided independence.
Findings include:
I. Resident #440
A. Resident status
Resident #440, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO) diagnoses included orthopedic fracture T11-T12 vertebra (backbone), hypertension, osteoporosis, asthma and depression. The resident had a history of falls.
The 9/29/22 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The staff assessment revealed the resident did not wear hearing aids and did not wear glasses with adequate vision.
The resident required extensive assistance from two staff members with bed mobility, transfers and locomotion and needed extensive assistance from one staff member with eating, toileting, personal hygiene and dressing. The resident was receiving physical therapy (PT) and occupational therapy (OT) from an outside provider.
The baseline care plan was documented as closed and completed on 9/20/22, however only one focus care plan area was completed under pain management. The residents baseline care plan was not fully developed to include all of the care focus areas, goals of care and interventions specifically for Resident #440 (cross-reference F655).
B. Observations and resident interviews
Resident #440 was observed on the following days and times lying in her bed with her lights off and the television was turned off. The resident's call light was not within reach and she either did not have water or fluids in her room or they were placed outside of her reach on her nightstand or on her bedside table positioned in the middle of the room (cross-reference F807).
On 9/26/22, Resident #440 was observed multiple times in her bed without access to preferred and necessary accommodations within her reach:
-At 8:50 a.m. she was observed lying in bed on left side facing the door, the television was turned off, her call light was wrapped around the positioning bar on the wall behind her, her cell phone was on the nightstand out of reach and she did not have water or fluids in her room.
-At 11:10 a.m. she was observed lying on her back in the dark looking out the door. She stated her television was not working and she was unable to watch the Broncos game the night before. She said her television had not worked since she was admitted to the facility on [DATE]. She asked for assistance to reach her call light.
-At 2:13 p.m. she was observed sitting in her wheelchair with her cellphone in her hand. Her call light and television remote were not within reach and she did not have fluids available in her room. She was sitting in the dark and the television was not turned on.
-At 2:53 p.m. she was observed lying in her bed facing the door. Her television was not turned on and she did not have any water in her room. She said her television was still not working and she would like to watch the news. She said she had not had water in her room all day and she was thirsty.
-At 3:32 p.m. a certified nursing assistant (CNA) exited her room. Resident #440 was lying in her bed with the television turned off and there was no water or fluids available in her room.
On 9/27/22, Resident #440 was observed multiple times in her bed without access to preferred and necessary accommodations within her reach:
-At 9:30 a.m. she was observed lying in bed. The television was not turned on and she did not have water in her room to drink.
-At 10:05 a.m. she was observed lying in her bed. She had a boost drink from breakfast sitting on her bedside table that was placed in the middle of the room out of her reach and her television was turned off.
-At 11:43 a.m. she was observed lying in her bed. Her call light was clipped to the room divider curtain hanging out of reach at the foot of her bed. She said she would like to have the blanket pulled up over her that was folded at the end of her bed, however she could not reach her call light to ask for assistance. CNA #6 was notified that the resident did not have her call light within reach and assisted her. CNA #6 apologized to the resident and said she should have her call light within reach at all times.
-At 3:31 p.m. she was observed lying in her bed. Her television was turned off and she had a cup of water on her bedside table for the first time since the observation period started. She said she would like to have her television on, however she did not know how to work the remote. She said she notified the staff but they were not able to help her. She said she was upset because she was not able to watch the Broncos game that was on television the other night.
On 9/28/22, Resident #440 was out of the building for much of the day. She returned at 2:36 pm. Staff assisted her back to her room and into her bed.
At 2:45 p.m. CNA #4 exited the room. Resident #440 was observed lying on her right side facing the wall. She needed assistance to turn over to her left side and was not able to roll on her own. Her television was not turned on and her cell phone and a styrofoam cup of water were on her bedside table out of her reach. Her call light was clipped to the blanket at the end of her bed out of her reach. She was observed trying to reach her call light and was unable to reach it. She asked for assistance to reach her call light. She said she was not able to turn on her television and wanted to watch television. She said she liked to watch local news. She said she wanted to roll from one side to the other, however she could not reach her call light for assistance. CNA #5 was notified that the resident needed assistance and apologized to her for not having the remote within reach. CNA #5 said she should have her call light within reach for her safety.
On 9/29/22 at 11:18 a.m. Resident #440 was observed lying in her bed on her right side. Her television was turned on, however the volume was off and her remote was on her bedside table placed in the middle of the room out of her reach. She had a cup of water placed on her nightstand behind her head and out of reach. She said she would like to have her water and remote within reach and asked for her cell phone. She said she was not able to reach her call light that was placed at the foot of her bed. She said she liked to do word searches, however her reading glasses were broken and she was not able to see well enough to do the word searches. She said she had an appointment tomorrow to get new glasses that were set up through her outside provider. She said she had a son and daughter involved in her care, however she was not sure if the staff here had talked to them about her care plan or care needs. She said no staff reviewed her care plan with her since her arrival to the facility.
C. Staff interviews
Registered nurse (RN) # 1 was interviewed on 9/29/22 at 11:30 a.m. She said she was new to Resident #440 and would look at her medical diagnoses and report from the other nurses to better understand her care. She said the baseline care plan was an important tool to understand a resident's care needs, however she also relied on getting reports from the other staff. She said Resident #440 had a history of falls and a fractured back. She said she should have her call light within reach at all times because of her history and diagnoses. She said in general it was not safe for residents to not have the call light within reach. She said she was not aware of her needing assistance with her television. She said all residents should have water and fluids available at the bedside unless there was a dietary restriction. She said she would check on Resident #440 and provide education to the staff regarding her needs.
Licensed practical nurse (LPN) #5 was interviewed on 9/29/22 at 11:50 a.m. She said Resident #440 needed assistance with her transfers and should not be transferring from her bed to her chair alone. She said she should have her call light within reach to notify the staff of her care needs. She said she should have her bedside table next to her to prevent her from transferring on her own and she would make sure her bedside table was next to her while lying in bed. She said she was not aware the resident could not reach the items placed on her nightstand and she was not aware that she needed assistance with her television.
The director of clinical services (DCS) and the director of nursing (DON) were interviewed on 9/29/22 at 4:24 p.m. The DON said the nursing staff had access to the resident's [NAME] which pulls identified care needs for each resident, however that information would not be accurate if the baseline care plan was not completed.
The DON and DCS said the call light should be within reach at all times when the resident is her room and her water, cell phone and television remote should also be within reach.
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 observations, record review, and interviews, the facility failed to develop and implement a baseline care plan for one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to develop and implement a baseline care plan for one (#440) of one resident reviewed for baseline care plans out of 39 sample residents.
Specifically, the facility failed to fully develop, review with the resident, and implement within 48 hours of admission, a person-centered baseline care plan for Resident #440 to include resident care focus areas, goals of care and interventions.
Findings include:
I. Resident status
Resident #440, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO) diagnoses included orthopedic fracture T11-T12 vertebra (backbone), hypertension, osteoporosis, asthma and depression. The resident had a history of falls.
The baseline care plan was documented as closed and completed on 9/20/22, however only one focus care plan area was completed under pain management.
The 9/29/22 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The staff assessment revealed the resident did not wear hearing aids and did not wear glasses with adequate vision.
The resident required extensive assistance from two staff members with bed mobility, transfers and locomotion and needed extensive assistance from one staff member with eating, toileting, personal hygiene and dressing. The resident was receiving physical therapy (PT) and occupational therapy (OT) from an outside provider.
II. Resident interview
Resident #440 was interviewed on 9/29/22 at 11:18 a.m. She said she had a son and daughter involved in her care, however she was not sure if the staff here had talked to them about her care plan or care needs. She said no staff reviewed her care plan with her since her arrival to the facility.
III. Record review
The baseline care plan was documented as closed and completed on 9/20/22, however only one focus care plan area was completed under pain management. The residents baseline care plan was not fully developed to include all of the care focus areas, goals of care and interventions specifically for Resident #440.
IV. Interviews
The social services director (SSD) was interviewed on 9/29/22 at approximately 4:00 p.m. She said the baseline care plan to help identify the resident's individual needs should be completed within the first week of the resident's arrival. She said a care conference should be scheduled within the first seven days, however a care conference has not been scheduled yet for Resident #440. She had been in the facility for ten days. She said she had left a message with the outside insurance provider's social worker, but had not heard back yet to schedule the care conference. She said the resident did have family involved in her care and she would normally invite the family, however she had not reached out to her family since her admission.
The director of clinical services (DCS) and the director of nursing (DON) were interviewed on 9/29/22 at 4:24 p.m. The DCS said the baseline care plan for Resident #440 had not been completed within the first 48 hours of her admission. She said she generated her comprehensive care plan on 9/27/22 once she identified her care plan was not completed. The DON said she would schedule staff education regarding completing the baseline care plan within the first 48 hours and why it was important to have it completed. The DON said the nursing staff have access to the resident's [NAME] which pulls identified care needs for each resident, however that information would not be accurate if the care plan was not completed.
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 interviews and record review, the facility failed to ensure two (#8 and #64) of four residents out of 39 sample residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure two (#8 and #64) of four residents out of 39 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities.
Specifically, the facility failed to provide Resident #8 and #64 with bathing according to their plan of care.
Findings include:
I. Facility policy and procedure
The Activities of Daily Living (ADL) policy and procedure, revised March 2018, was provided by the nursing home administrator (NHA) on 9/29/22 at 5:30 p.m.
It revealed, in pertinent part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene including bathing, dressing, grooming, and oral care.
II. Resident #64
A. Resident status
Resident 64, younger than 65, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included type 2 diabetes (abnormal glucose), chronic kidney disease (decreased kidney function) and obesity.
The 8/24/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance of two people with bed mobility, transfer, dressing, toileting and personal hygiene.
B. Resident interview and observations
Resident #64 was interviewed on 9/26/22 at 11:51 a.m. He said he had not received bathing since he was admitted to the facility on [DATE]. He said he would like to have a shower or at least a bed bath.
His hair was observed to be greasy and uncombed.
On 9/27/22 at 10:56 a.m. Resident #64 said he had still not received a shower. He said he needed assistance from staff because he could not bathe on his own.
His hair appeared wet and greasy
On 9/28/22 at 2:30 p.m. Resident #64 said he still had not been offered any showers. He said he was told when he was admitted that showers were twice per week, but he had yet to be offered a shower.
C. Record review
The ADL care plan, revised 8/29/22, revealed the resident had an ADL self-care deficit related to weakness, pain and a new environment. It indicated the resident required staff assistance of two people for bathing.
The 8/17/22-9/28/22 point of care (POC) documentation revealed the resident had received a shower on 9/28/22 (during the survey process).
D. Staff interviews
Certified nurse aide (CNA) #1 was interviewed on 9/29/22 at 11:10 a.m. He said most residents received bathing twice per week. He said bathing was documented in POC.
CNA #1 said Resident #64 required two person assistance for all care.
The director of nursing (DON) and the director of clinical services (DCS) were interviewed on 9/29/22 at 4:22 p.m. The DON said dependent residents should be offered showers based on their preferences. She said most residents preferred showers or bed baths twice per week with set times and days.
She said bathing was documented by the CNAs in POC. She said Resident #64 should have been offered a shower since his admission to the facility. III. Resident #8
A. Resident status
Resident #8, age under 65, was admitted on [DATE]. According to the September 2022 computerized physician orders, diagnoses included cerebellar stroke syndrome, aphasia (difficulty with speech), muscle wasting and atrophy, dependence on wheelchair, and ataxia (poor muscle control).
The 7/1/22 minimum data set assessment indicated the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. It indicated the resident could not speak but was usually able to make himself understood. It indicated the resident did not reject care. It indicated the resident required extensive two person assistance for activities of daily living.
B. Resident interview
Resident #8 was interviewed on 9/26/22 at 4:30 p.m. The resident was unable to communicate verbally and utilized an alphabet board that he held with one hand while he pointed to letters to spell words with the other hand. The resident reported he had to beg for his showers. He reported he did not have scheduled showers.
The resident's skin appeared shiny or greasy.
C. Record review
The activities of daily living care plan, revised 6/1/22, indicated the resident had a self-care performance deficit related to a stroke. Interventions included hoyer lift for all transfers, two person assist with bathing, providing sponge bath when full bath or shower cannot be tolerated.
Shower records were provided by the nursing home administrator (NHA) on 9/29/22 at 9:19 a.m. The records indicated Resident #8 received two showers in July 2022, three showers in August 2022, and four showers in September 2022. One shower refusal was marked in July 2022.
D. Staff interviews
Licensed practical nurse (LPN) #3 was interviewed on 9/29/22 at 11:14 a.m. She said Resident #8 was able to make choices on his own and he rarely refuses care or showers.
Certified nurse aide (CNA) #3 was interviewed on 9/29/22 at 11:18 a.m. She said Resident #8 had occasionally refused a bath or shower and she would offer one later or tell the nurse.
The director of nursing (DON) was interviewed on 9/29/22 at 4:22 p.m. She said showers were offered based on resident preference but most residents preferred at least twice a week and as needed. She said if a resident refused a shower the nurse would reapproach or educate. She said if a shower was given at a later time it may not be documented. She said Resident #8 had come to her to request a shower on occasion.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a program to support residents in their choi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a program to support residents in their choice activities, designed to meet the interests and support the physical, mental, and psychosocial well being of each resident, encouraging independence for one (#440) of one out of 39 sample residents.
Specifically, the facility failed to ensure Resident #440 was offered and assisted with independent leisure activities in her room.
Cross-referenced to F558 failure to accommodate resident needs.
Findings include:
I. Resident status
Resident #440, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO) diagnoses included orthopedic fracture T11-T12 vertebra (backbone), hypertension, osteoporosis, asthma and depression. The resident had a history of falls.
The 9/29/22 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The staff assessment revealed the resident did not wear hearing aids and did not wear glasses with adequate vision.
The resident required extensive assistance from two staff members with bed mobility, transfers and locomotion and needed extensive assistance from one staff member with eating, toileting, personal hygiene and dressing. The resident was receiving physical therapy (PT) and occupational therapy (OT) from an outside provider.
II. Observations and resident interviews
Resident #440 was observed on 9/26/22 through 9/29/22 lying in her bed with her lights off with the television turned off and there were no independent leisure activities or materials observed in her room. She did have a cell phone in her room, however it was not always within reach for her to use. She did not have the ability to use her remote or turn on her television by herself. She did not have her glasses available to her and was not able to participate in coloring or word searches during the observation period.
Resident #440 was interviewed on 9/26/22 at 11:10 a.m. She said she wanted to watch her television, however she did not think it was working. She said she tried to turn it on and she could not get it to work. She said she asked the staff to assist her the night before to watch the Broncos game, however they could not get it to work.
Resident #440 was interviewed on 9/27/22 at 3:31 p.m. She said she would like to watch her television, however she could not get it to work or change channels. She said it would turn on, however she could not get the remote to work because it was too small. She said she was upset because she missed watching the Broncos game the other night.
Resident #440 was interviewed on 9/29/22 at 11:18 a.m. She said she would like to have her water and remote within reach and asked for her cell phone. She said she liked to do word searches, however her reading glasses were broken and she was not able to see well enough to do the word searches. She said she had an appointment tomorrow to get new glasses that were set up through her outside provider.
III. Record review
Review of the residents activity assessment revealed the assessment was completed on 9/27/22, seven days after her admission. The MDS admission assessment section F preferences for routine and activities identified using a phone, listening to music, keeping up with the news and participating in her favorite activities were very important to her.
The activity initial progress note dated 9/27/22 revealed the resident enjoyed keeping up with the news, watching soap operas and westerns, listening to jazz music and doing word searches and coloring in her room.
-However, the resident had been admitted to the facility on [DATE] and did not have her activity assessment and activity preferences identified until seven days after her admission and not within five days (as indicated by the activity director below).
IV. Staff interviews
The activity director (AD) was interviewed on 9/29/22 at 12:45 pm. She said she completed the initial MDS assessment for a new admission within the first five days of admission. She then completed the full activity assessment within the first 14 days and that information was added to the resident's care plan. She said she did conduct the initial assessment for Resident #440, however it was not entered into the medical record within the first five days. She said she also conducted an assessment of her preferences called The Story of Me, however that was completed on 9/27/22 seven days after her admission.
She said she identified that Resident #440 enjoyed watching television and doing word searches and coloring, however she had been putting the word searches and coloring in her nightstand drawer and was not doing the activities currently. She said she was not aware that the resident needed glasses and that she was having difficulty seeing her independent leisure activities. She said she was not aware that the resident could not turn her television on and did not know how to use her television remote and had not been able to watch her television since her time of admission. She said her activity staff provide a morning check in and offer independent leisure activities daily. She said her staff were not aware of the resident's needs and other staff did not notify her of any concerns. She said the activity staff were not in the building 24 hours a day and the leisure needs of the residents was a facility responsibility and that all the staff should assist the residents. She said the nurse conducted an initial assessment as well as social services to help identify if a resident has any ancillary needs like glasses. She said she did not see any notes in Resident #440's medical chart regarding needing glasses or having an appointment to replace her glasses. She said she would follow up with the resident immediately and offer her assistance.
V. Facility follow-up
Review of Resident #440 activity progress notes on 9/29/22 at 4:00 p.m. revealed the AD entered in a new progress note dated 9/29/22 at 3:57 p.m. It read that the AD showed the resident how to operate her remote for her television as well as provided her with some reader glasses until her upcoming eye appointment. The resident lost her glasses prior to admission to the facility. The AD educated the resident and will offer assistance daily with her television needs.
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 observations, record review and interviews the facility failed to ensure that residents received treatment and care in ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (#72) of four out of 39 sampled residents.
Specifically, the facility failed to ensure a treatment order was in place for an open area for Resident #72.
Finding include:
I. Facility policy and procedure
The Pressure Injury Prevention policy and procedure, reviewed October 2019, was provided by the nursing home administrator on 9/29/22 at 5:30 p.m.
It revealed, in pertinent part, Weekly, the facility will complete a thorough comprehensive skin evaluation in the electronic medical record on all residents. A skin evaluation may be completed more frequently if deemed necessary by nursing management or plan of care.
The facility nursing assistants will complete a skin observation and document findings by completing the every shift skin observation question in the electronic medical record (point of care). The skin observation documentation is reviewed by a supervisor or designee daily. If the supervisor identifies any abnormal findings it will be reported to the director of nursing (DON) for additional follow up and review.
II. Resident #72
A. Resident status
Resident #72, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, encephalopathy (altered brain function), and chronic kidney disease (loss of kidney function).
The 9/6/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. He required supervision with dressing and was independent with bed mobility, transfers, toileting and personal hygiene.
B. Resident interview and observation
Resident #72 was observed on 9/26/22 1:15 p.m. with a bandage to his right ear. The bandage had dried blood around the edges and was undated.
Resident #72 said he had a cancerous area removed when he went to a dermatologist appointment on 9/20/22. He said the facility did not perform any treatments on the open area to his right ear.
On 9/27/22 11:01 p.m. Resident #72 was observed ambulating in the hallway with a treatment dressing to the right ear. The dressing had dried blood around the edges and was undated. It appeared to be unchanged from 9/26/22.
C. Record Review
The August 2022 and September 2022 CPO, reviewed on 9/26/22, did not reveal any treatment orders for the lesion to the resident's right ear.
The skin integrity care plan, revised on 9/21/22, documented the resident was at risk for skin alterations and required weekly skin assessments by a nurse and skin check daily with activities of daily living (ADL) care.
The 7/8/22, 7/14/22, 7/28/22, 8/4/22, 8/17/22, 8/24/22, 8/31/22, 9/7/22, 9/14/22, 9/21/22, and 9/24/22 weekly skin assessments documented the resident's skin was intact.
The 8/10/22 skin assessment documented the resident had stitches to the right ear.
The 8/12/22 physician progress note documented the resident had a malignant melanoma of the right external auricular canal (ear). It indicated the resident had an excision of the melanoma on 7/19/22 and would have another excision with the dermatologist on 9/20/22.
It documented the following wound care orders for the resident's right ear from 7/19/22 to be discontinued on 8/12/22.
-Cleanse daily with soap and water, apply vaseline to the incision site and cover with band aid every day until the sutures are removed.
The 9/20/22 dermatology progress notes documented the resident had another excision of a malignant melanoma to the right ear. A dry sterile dressing was applied to the right ear.
D. Staff interviews
Licensed practical nurse (LPN) #1 was interviewed on 9/29/22 at 8:30 a.m. She said skin assessments were completed on every resident weekly. She said any new skin condition should be noted and reported to the nursing supervisor. She said all wounds should have a physician ordered treatment in place.
She said a treatment order was put in place on 9/28/22 for the lesion to the resident's right ear. She confirmed there had not been a treatment ordered for the resident's right ear prior to the one entered that day.
The director of nursing (DON) and the director of clinical services (DCS) were interviewed on 9/29/22 at 4:22 p.m. The DON said weekly skin assessments were completed on every resident by the nurse. She said any new skin conditions should be documented on the skin assessment. She said the nursing supervisor and the physician should be notified to obtain a treatment order.
She said all skin conditions should have a treatment order in place.
The DON said the facility had a difficult time receiving progress notes from the resident's primary care physician, who was an outside provider. She confirmed the physician notes and dermatology notes were not included in the resident's medical record until the survey process, when they were requested.
The DON confirmed the facility was responsible for the resident's care and ensuring the resident received treatments as ordered by his primary care physician and other outside providers. She confirmed the facility were not aware of the treatment orders because they had not received the physician progress notes from the excision on 7/19/22. She said she did not know if the facility staff had contacted the physician to obtain the notes from the dermatology and primary care visit. She said the facility staff had contacted the dermatologist that day (during the survey process) for the physician notes from the 7/19/22 and 9/20/22 visits.
She said the nurse should have contacted the physician when the blood was observed around the resident's right ear and obtained a treatment order.
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 observations, record review and interviews, the facility failed to ensure two (#44 and #77) of six out of 39 sample res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure two (#44 and #77) of six out of 39 sample residents with limited range of motion (ROM) received appropriate treatment and services.
Specifically the facility failed to:
-Ensure Resident #44 and #77 were provided braces, for contracture management, according to their plan of care; and,
-Ensure parameters were clearly identified to indicate the length of time and how often the braces should be donned and doffed by the Resident #44 and #77.
Findings include:
I. Resident #44
A. Resident status
Resident #44, age younger than 65, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included paralytic syndrome (loss of motor function to the body), contracture of the right hand, and hypertension.
The 8/8/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance of one person with bed mobility, dressing, toileting and personal hygiene and limited assistance of one person with transfers.
B. Resident interview and observations
Resident #44 was interviewed on 9/26/22 at 3:20 p.m. He said he had a contracture to the pinky finger on the right hand. He said he was supposed to wear a splint to his right pinky finger for three hours every day. He said he required staff assistance with applying the brace because of his impaired mobility.
-The resident was not wearing a splint to his right pinky finger.
On 9/28/22 at 9:25 a.m. Resident #44 was observed in the common area. He was not wearing the brace to the right pinky finger.
Resident #44 was interviewed at 2:15 p.m. He said if he had assistance with applying the brace he would wear it every day. He said he was only able to wear the brace on days that he received physical therapy, because the therapist assisted him to put on the brace.
C. Record review
The activities of daily living (ADL) care plan, revised 8/15/22, documented the resident had a self-care deficit related to paralysis. The interventions included wearing a pinky splint for three hours with a progression to four hours without complaints of pain from the resident or signs of skin breakdown.
The September 2022 CPO did not reveal an order for staff to assist residents with application of splints.
A review of the certified nurse aide (CNA) tasks on 9/29/22 did not reveal instructions to assist the resident with the donning and doffing of the right pinky finger brace.
II. Resident #77
A. Resident status
Resident #77, age younger than 65, was admitted on [DATE]. According to the September 2022 CPOs, the diagnoses included bipolar disorder, respiratory failure with hypoxia (not enough oxygen in circulation), hemiplegia (paralysis affecting one side) due to cerebral infarction (affected blood flow to the brain), dementia (impaired memory), and type two diabetes (impairment of glucose regulation).
The 9/7/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance of two people with bed mobility, transfers, dressing, toileting and personal hygiene.
B. Resident interview and observations
On 9/27/22 at 1:28 p.m. Resident #77 was observed sitting in her room in the wheelchair. The resident's left hand had a contracture. Resident #77 said she had a brace, but it went missing approximately six months ago. She said she was waiting to get a new brace.
On 9/28/22 at 10:59 a.m. the resident was observed in the hallway by the nurses station. She had her left hand tucked into her side between the wheelchair and her left thigh, no brace was in place.
On 9/29/22 at 9:52 a.m. Resident #77 was observed self-propelling her wheelchair backwards from the dining room. Her left hand was hanging down by the wheel of the wheelchair with no brace in place.
C. Record review
The ADL care plan, revised 8/15/22, documented she had a contracture to the left upper extremity. The interventions included assisting the resident with placement of splint/sling to the left upper extremity every morning and removing it in the evening as the resident tolerated by the certified nurse aide (CNA).
III. Staff interviews
CNA #4 was interviewed on 9/29/22 at 10:06 a.m. She said Resident #44 had a pinky brace that was applied by an occupational therapist or restorative CNA. She said Resident #44 was unable to apply the brace without assistance.
CNA #1 was interviewed on 9/29/22 at 11:10 a.m. He said Resident #77 sometimes wore a brace to the left arm. He said she required assistance to apply the brace. CNA #1 located the brace in the resident's room, on top of the closet and underneath a blanket and various articles of clothing. He said the left arm brace could be applied by a CNA, restorative CNA, nurse or a therapist.
The restorative coordinator (RC) was interviewed on 9/29/22 at 11:54 a.m. She said the CNA and the nurses would assist the resident to apply the brace.
She said a physician's order should be in place that specified how often the brace should be applied and the duration. She confirmed a physician's order was not in place for the application of the braces for both Resident #44 and Resident #77.
The director of nursing (DON) and director of clinical services (DCS) were interviewed on 9/29/22 at 4:22 p.m. The DON said a physician's order should be in place for the application of the braces. She said the orders typically came from the therapy department, which included the resident's restorative nursing program. She said once the resident was finished with the restorative nursing program, the CNA or nurse should assist the resident with the application of the brace.
The DON said the application of braces should be identified in the CNA tasks and should include which days and duration the brace should be applied. She said if a resident refused to wear the brace, it should be documented in the resident's care plan.
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** III. Resident #44
A. Resident status
Resident #44, age younger than 65, was admitted on [DATE]. According to the September 2022 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #44
A. Resident status
Resident #44, age younger than 65, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included paralytic syndrome (loss of motor function to the body), contracture of the right hand, and hypertension.
The 8/8/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance of one person with bed mobility, dressing, toileting and personal hygiene and limited assistance of one person with transfers.
B. Resident interview and observations
On 9/26/22 at 2:30 p.m. one can of Aspercreme Lidocaine 4% dry spray, one tube of Aspercreme Lidocaine 4% cream and two tubes of Bacitracin ointment were observed on a table in Resident #44's room.
Resident #44 said he used the Aspercreme for his muscles and cramps. He said the Bacitracin ointment was for a wound that was healed. He said the cream had not been used in a while.
C. Record review
The August 2022 CPO revealed a physician's order for Aspercreme Lidocaine 4% cream. It did not reveal an order for the Aspercreme Lidocaine 4% dry spray or the bacitracin ointment.
A review of the resident's medical record on 9/26/22 at 3:00 p.m. did not reveal documentation a medication self-administration assessment had been completed for Resident #44 to assess if it was safe for the resident to have medications at the bedside. It did not reveal documentation that self-administration was included in the resident's comprehensive care plan.
D. Staff interviews
Certified nurse aide (CNA) #4 was interviewed on 9/29/22 at 10:06 a.m. She said residents were not allowed to keep medications in their room. She said if they observed any medications, the CNA should notify the nurse. She said Resident #44 required assistance with opening cream bottles due to the contracture to the resident's right hand.
Licensed practical nurse (LPN) #4 and LPN #5 were interviewed on 9/29/22 at 10:39 a.m. She said medications, medicated creams or ointments should not be kept in the resident's room. She said social services was responsible for arranging a self-administration assessment if a resident wanted to keep medications or ointments at their bedside.
LPN #4 confirmed a self-administration assessment had not been completed for Resident #44.
LPN #5 removed Aspercreme with Lidocaine 4 % dry spray and cream, two tubes of Bacitracin, two tubes of Triad cream (wound cream) and wound cleanser from Resident #44's room.
Based on observations, interviews, and record review the facility failed to provide an environment free of accidents and hazards for two (#44 and #50) of five out of 39 sample residents.
Specifically, the facility failed to ensure Resident #8 and Resident #44 did not have medications and supplements in their rooms.
Findings include:
I. Facility policy
The Self-Administration of Medications policy and procedure, revised February 2021, was provided by the director of clinical services on 9/29/22 at 5:45 p.m. It read, in pertinent part, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them.
II. Resident #50
A. Resident status
Resident #50, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included chronic kidney disease, hypertension, and other symptoms and signs involving cognitive functions and awareness.
The 8/9/22 minimum data set assessment indicated the resident had both short and long term memory problems and was independent with cognitive skills for daily decision making. It indicated the resident was independent with activities of daily living.
B. Resident interview and observations
Resident #50 was interviewed on 9/26/22 at 2:58 p.m. The resident said he was not a resident of the facility and he was here to support his wife who was a resident (however, the resident was admitted to the facility). Multiple bottles that appeared to be supplements were on a bedside table on his side of the room that he shared with his wife.
Resident #50 was interviewed again on 9/28/22 at 1:57 p.m. He said he took supplements and kept them on his bedside table. He said he liked to do his own research on what to take.
-He would not allow the surveyor to read the labels on the supplements.
C. Record review
The September 2022 CPO revealed the following supplements and over the counter medications:
-Aspirin capsule 81 milligrams (mg) one time a day for anticoagulation, ordered 12/3/21;
-Multivitamin tablet one tablet one time a day for supplementation, ordered 12/3/21;
-Vitamin B12 Tablet 500 mg one time a day for supplement, ordered 12/3/21;
-Omega-3 capsule two times a day for supplement, ordered 12/3/21; and,
-Tums Tablet 500 mg every six hours as needed for heartburn, ordered 12/3/21.
The behavior care plan, revised 8/15/22, indicated Resident #50 had behaviors related to declining care. It indicated he would state he was not a resident and would decline care and medications. Interventions included administering medications as ordered, behavior monitoring, providing positive interactions, and explaining procedures prior to care.
-There was no care plan related to self administration of medications.
D. Staff interviews
Licensed practical nurse (LPN) #1 was interviewed on 9/28/22 at 2:15 p.m. She said Resident #50 was particular about his medications. She said he allowed staff to keep prescription medication but he kept his supplements and over the counter medications. She said the physician was aware of this and allowed it.
The director of nursing (DON) was interviewed on 9/29/22 at 4:22 p.m. She said residents should not keep over the counter medications or supplements at the bedside. She said an assessment should be completed if a resident was able to self administer and then it would be discussed with the physician. She said the resident would also have a corresponding care plan related to self administered medications. She said she would expect medications to be locked to ensure residents who may not be cognitively intact could not access the medications. She said Resident #50 did not have an assessment or corresponding care plan related to his over the counter medications and supplements in his room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure three residents (#29, #36 and #64) of five out of 39 sample...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure three residents (#29, #36 and #64) of five out of 39 sampled residents were free of unnecessary medication as possible.
Specifically, the facility failed to:
-Ensure informed consent was obtained prior to administration of psychotropic medication for Resident #29 and #64; and,
-Ensure a gradual dose reduction (GDR) recommendation was followed for Resident #36.
Findings include:
I. Facility policy and procedure
The Psychopharmacological policy and procedure, reviewed 9/28/22, was provided by the nursing home administrator (NHA) on 9/29/22 at 6:00 p.m.
It revealed, in pertinent part, The community supports the appropriate use of psychopharmacological drugs that are therapeutic and enabling for residents suffering from mental illness. The psychopharmacological/behavior review Committee will make recommendations to the primary care physician for gradual dosage reduction of psychopharmacological drugs as recommended by Federal regulations. The previous month's committee recommendations are reviewed to ensure follow-up and evaluation of outcomes.
II. Resident #64
A. Resident status
Resident #64, younger than 65, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included type 2 diabetes, chronic kidney disease (decreased kidney function), and obesity.
The 8/24/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance of two people with bed mobility, transfers, dressing, toileting and personal hygiene.
B. Record review
The September 2022 CPO documented the following physician order:
- Bupropion hcl XL 300 milligram (mg): one tablet daily for depression ordered 8/17/22.
-A review of the resident's medical record did not reveal documentation that consent was obtained prior to the administration of the Bupropion medication. The facility was unable to provide documentation of consent prior to the end of the survey (9/26/22-9/29/22).
III. Resident #29
A. Resident status
Resident #29, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO) diagnoses included schizophrenia, depression and hallucinations.
The 7/25/22 MDS assessment revealed the brief interview for mental status (BIMS) was not completed. She did have a diagnosis of depression and schizophrenia and received an antipsychotic and antidepressant seven out of the seven day review period.
B. Record review
The September 2022 CPO included:
-Duloxetine HCL (cymbalta) delayed release sprinkle 30 milligrams (mg), give two capsules by mouth two times a day for depression associated with traumatic brain injury. Order date of 5/5/22;
-Quetiapine fumarate (seroquel) tablet 50 mg, give one tablet by mouth three times a day for schizophrenia. Order date of 5/5/22;
-Cariprazine HCL capsule 6 mg, give one capsule by mouth one time a day for schizophrenia. Order date of 5/5/22, and;
-Divalproex sodium tablet delayed release 500 mg, give one tablet by mouth one time a day for bipolar disorder. Order date of 5/5/22.
The care plan, revised on 7/13/22, identified the resident had a diagnosis of schizophrenia and used antipsychotic medication for symptoms and behaviors related to the diagnosis. She also had a diagnosis of depression and used antidepressant medication.
Review of the resident's record revealed there were no consents or education provided to the resident and/or representative that documented for the use of her antipsychotics and antidepressants listed above. A request for the consents was provided to the nursing home administrator (NHA) on 9/29/22 at 3:46 p.m. and were not provided by exit of the survey on 9/29/22.
IV. Resident #36
A. Resident status
Resident #36, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, the diagnoses included dementia with behaviors, type two diabetes, osteoarthritis (joint cartilage breakdown) and dysphagia (impaired swallowing).
The 8/2/22 MDS assessment revealed the resident had a severe cognitive impairment with a brief interview for mental status score of three out of 15. She required extensive assistance of one person with dressing, personal hygiene, and toileting and limited assistance of one person for transfers.
B. Record review
The September 2022 CPO documented the following physician's order:
-Zyprexa 5 MG at bedtime, every day for dementia with behaviors-ordered 6/10/21.
The 8/11/22 psychiatry progress notes documented a recommendation to reduce the Zyprexa from 5 MG at bedtime every day to 2.5 MG at bedtime every day. It indicated the physician would review the recommendation of the dose reduction in a couple months.
-A review of the resident's medical record on 9/29/22 at 3:00 p.m. revealed the resident was still being administered Zyprexa 5 MG at bedtime, instead of the dose reduction of 2.5 MG at bedtime as recommended by the psychiatrist.
V. Staff interviews
The director of nursing (DON) and the director of clinical services (DCS) were interviewed on 9/29/22 at 4:22 p.m. The DON said the facility held a psych-pharm committee meeting where they reviewed all residents who are on psychotropic medications. She said, in that meeting, the committee discussed gradual dose reductions (GDR). She said she was responsible to ensure the recommendations from the committee meeting were written and monitored.
The DON said she was not aware of the GDR recommendation for Resident #36. She confirmed the GDR recommendation made by the psychiatrist on 8/11/22 had not been followed up on or followed.
The DON said consent should be obtained for all psychotropic medications prior to the administration of the medication. She said the consent should be documented in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0807
(Tag F0807)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure drinks and fluids were provided consistent w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure drinks and fluids were provided consistent with the preferences and choices for one (#440) of one resident reviewed for hydration out of 39 sample residents.
Specifically, the facility failed to ensure Resident #440 was provided water and drinks of choice daily and the drinks were within reach when provided in her room.
Findings include:
I. Resident status
Resident #440, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO) diagnoses included orthopedic fracture T11-T12 vertebra (backbone), hypertension, osteoporosis, asthma and depression. The resident had a history of falls. The resident had a regular diet with thin liquids and did not have any fluid restrictions identified.
The 9/29/22 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The staff assessment revealed the resident did not wear hearing aids and did not wear glasses with adequate vision.
The resident required extensive assistance from two staff members with bed mobility, transfers and locomotion and needed extensive assistance from one staff member with eating, toileting, personal hygiene and dressing. The resident was receiving physical therapy (PT) and occupational therapy (OT) from an outside provider.
II. Observations and resident interviews
Resident #440 was observed through continuous observations on 9/26/22 through 9/27/22 without fluids or water available at bedside.
On 9/26/22 at 2:53 p.m. the resident was observed sitting in her wheelchair in her room. She did not have any fluids available to her in her room. She said she was thirsty and she did not have water in her room all day.
On 9/27/22 at 2:45 p.m. the resident was observed lying in her bed with a cup of water on her bedside table. The bedside table was placed in the middle of the room and was not within reach for the resident to access. This was the first time during the observation period that the resident had water available in her room. She said she was not able to reach her bedside table with her water and would like it moved closer to her.
On 9/29/22 at 11:18 a.m. the resident was observed lying in her bed with a cup of water placed on her nightstand which was behind her to the right of her bed. The water was not within reach for the resident to access. She said she was thirsty and would like to have her water closer to her so she could reach it.
III. Record review
The nutritional assessment conducted on 9/27/22 revealed the resident had a regular texture and regular diet with thin liquids. She did not have any fluid restrictions identified. She had a daily fluid intake goal of 1485-1760 milliliters per day.
IV. Staff interviews
Registered nurse (RN) # 1 was interviewed on 9/29/22 at 11:30 a.m. She said all residents should have water and fluids available at the bedside unless there was a dietary restriction.
She said Resident #440 did not have any fluid restrictions and should have water offered and available at bedside.
Licensed practical nurse (LPN) #5 was interviewed on 9/29/22 at 11:49 a.m. She said Resident #440 should have water available in her room and should have it next to her within reach. She observed the water cup on the nightstand behind the resident's head to the right of the bed. She said she was not aware the resident could not reach items placed on the nightstand and would move her water to the bedside table. She said her bedside table should not be placed in the middle of the room and should be next to her while in her bed or in her wheelchair. She said she would review with the rest of the staff and have them pay more attention to her needs.
The director of clinical services (DCS) and the director of nursing (DON) were interviewed on 9/29/22 at 4:24 p.m. The DON and DCS said fluids should be within reach at all times when the resident was in her room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled in two medication carts and one storage room out of ...
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Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled in two medication carts and one storage room out of four medication carts and two storage rooms.
Specifically facility failed to:
-Ensure loose medications in carts were properly disposed of;
-Ensure the temperature of the refrigerator was kept within a safe range;
-Ensure medications were not poured from one bottle to another;
-Ensure medication carts were locked when unattended; and,
-Ensure proper disposal of medications.
Findings include:
I. Facility policy and procedure
The Medication Storage policy, undated, was provided by the facility on 9/29/22 at 5:30 p.m. It revealed, in pertinent part,, the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature. Only persons authorized to prepare and administer medications have access to locked medications. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses station or other secured location. Medications are stored separately from food and are labeled accordingly.
II. Observations
On 9/28/22 at 4:06 p.m., licensed practical nurse (LPN) #6 dispensed the medication Labetalol (high blood pressure medication). The medication touched her bare hand, she then disposed of the medication into the sharps container on the north back medication storage cart.
-LPN #6 should have disposed of the medication in the drug buster, see staff interview below.
On 9/29/22 at 12:55 p.m. review of the south front cart revealed a dental cream and hand sanitizer stored next to inhalers and three loose pills within the cart drawer.
-At 2:10 p.m., the south treatment cart was observed unlocked outside of a resident's room.
-At 2:15 p.m., the front south cart was observed unlocked and unattended. There were residents and certified nurse aides (CNAs) in the area of the cart.
-At 2:20 p.m. LPN #1 had already passed her cart onto the oncoming shift nurse. She proceeded to walk into the medication room on the north wing, the main door was unlocked and unattended.
-At 2:25 p.m., LPN #6 reviewed the medication room on the north wing with a surveyor. RN #2 walked into the medication room with no keys used to open the door.
The staff stored their lunches, water bottles, backpacks and purses were stored in the medication room.
Registered nurse (RN) #2 entered the room and took over for LPN #6. RN #2 assisted with opening the refrigerator in the medication room, he found the refrigerator unlocked. Insulin, vaccines, and Ativan (schedule two controlled medication), were stored in the refrigerator.The Ativan, was locked in a separate locked box. Review of refrigerator temperature at 50 degrees fahrenheit confirmed by RN #2. Review of the refrigerator temperature log revealed nine days in from 9/1/22 to 9/29/22 to be out of range and above 46 degrees fahrenheit, confirmed by RN #2.
Review of medication cart on the north back hall at 2:45 p.m. revealed 44 loose pills on the cart, confirmed by RN #1. The medications were disposed of in the drug buster. A lantus insulin pen failed to have an open date.
III. Staff interviews
LPN #1 was interviewed on 9/29/22 at 12:55 p.m. LPN #1 said the bottles did not have open dates because they fill the smaller bottles from a larger bottle so it fits in the cart better. She said when medications needed to be disposed of they needed to be put into a container with a lid specialized in medication disposal called a drug buster. She said if it was a controlled substance then two nurses need to be present when it was disposed of properly in the drug buster.
RN #2 was interviewed on 9/29/22 at 2:30 p.m. while reviewing the medication room with a surveyor. He said the medication room and refrigerator should be kept locked at all times due to the Ativan (controlled substance) being stored in the refrigerator. The refrigerator temperature should be kept between 32 and 46 degrees fahrenheit. He said the refrigerator was currently four degrees above the safe temperature range. There should be no food or staff personal items stored in the medication room.
RN #1 was interviewed on 9/29/22 at 2:45 p.m. RN #1 said medications like lantus (insulin) needed an open date to ensure they are used by a certain date or discarded if they expired. She said loose pills needed to be discarded timely so they did not get into the wrong hands. If a medication needed to be disposed of they went into the drug buster but if it was a controlled medication two nurses needed to dispose of the medication properly. She said medication carts and rooms needed to be locked at all times when a nurse was not present.
The director of nursing (DON) and the director of clinical services (DCS) were interviewed on 9/29/22 at 4:22 p.m. The DON said medications needing to be disposed of should go into the drug buster held in each medication cart and not be disposed of in the sharps container.
She said medications should not be loose in the cart, if found they should be placed in the drug buster. She said it was very easy to pop medications out of cards and it was the responsibility of the nurse to keep the cart clean. The cart should be cleaned weekly and wiping the top every shift. The pharmacist came out if there was an issue identified or to maintain a broken lock. A facility consultant might do a cart review.
She said the medication rooms should be kept locked at all times. The room was to be locked due to the two lock requirement for narcotic medications. She said if a refrigerator contained controlled medications it was to be locked.
The DON said refrigerator temperatures should be checked daily and if out of range the nurse should be contacting the maintenance department. Medications needed to be stored within manufacturer's guidelines. If the refrigerator temperature was not between 36 and 46 degrees fahrenheit it was out of range. She said the refrigerator temperature of 50 degrees was above the temperature range. She said medications would then need to be sent back to the pharmacy for destruction and to get them replaced.
The DON said open bottles could not be filled with another bottle of the same medication because the bottles may have different expiration dates.
The DON said no food or personal items should be stored in the medication room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on resident interviews, staff interviews, record review, and the tasting of the test tray, the facility failed to consistently serve food that was palatable and at the proper temperature.
Speci...
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Based on resident interviews, staff interviews, record review, and the tasting of the test tray, the facility failed to consistently serve food that was palatable and at the proper temperature.
Specifically, the facility failed to ensure resident food was palatable in taste, texture, appearance, and temperature.
Findings include:
I. Resident interviews
Resident #33 was interviewed on 9/26/22 at 10:09 a.m. She said she did not like the food at the facility. She said she liked to eat in her room but her tray would arrive without the right condiments or an item would be missing. She said the food was cold and needed more flavor.
Resident #23 was interviewed on 9/26/22 at 10:46 a.m. She said she did not like the food. She said she preferred to eat in her room. She said she had been served food that was still frozen and cold. She said the food tasted bad and needed more seasoning.
Resident #50 was interviewed on 9/26/22 at 2:58 p.m. He said he did not like the food because it was greasy and unhealthy. He said he had complained to staff but things never improved. He said he preferred to purchase his own food.
Resident #86 was interviewed on 9/27/22 at 11:16 a.m. He said he did not like the food at the facility. He said the taste of the food was not good.
II. Resident group interview
On 9/28/22 at 10:00 a.m., the group interview was conducted with five residents (#7, #14, #17, #35 and #58) present.
Resident #14 said the food was served cold sometimes and did not taste good. She said the dinner on the previous evening was cold.
Resident #58 said she preferred to eat in her room. She said sometimes the meal trays were not passed to residents in a timely fashion and were served cold.
III. Record review
Review of the Resident Council minutes from 4/13/22 to 9/14/22 revealed the following concerns about the palatability and temperature of food:
-The minutes from the 4/13/22 meeting indicated residents reported the vegetables served during meals were soggy and the liquid was running into other food on their plate.
-The minutes from the 6/8/22 meeting indicated residents reported trays delivered to rooms were served cold.
-The minutes from the 7/12/22 meeting indicated residents reported meals served in the dining room were cold and the food being served was not what was ordered.
-The minutes from the 8/10/22 meeting indicated residents reported room trays were left in the hallway for long periods of time prior to being passed into resident rooms.
-The minutes from the 9/14/22 meeting indicated residents reported food was not looking appetizing or tasting good.
The Food Committee minutes from 4/13/22 to 9/14/22 revealed the following:
-The minutes from the 4/13/22 meeting indicated the residents reported the room trays were cold and the playing and presentation of the food was lacking.
-The minutes from the 5/11/22 meeting indicated the residents reported the meals needed additional seasoning.
-The minutes from the 6/8/22 meeting indicated the residents reported the food was served cold. The notes indicated bases and domes were ordered to aid in temperature control for room trays.
-The minutes from the 7/13/22 meeting indicated the residents reported the food served in the dining room was cold and the room trays were cold.
-The minutes from the 8/10/22 meeting indicated the residents reported food did not look appealing and the plating was not good. It noted the vegetables were runny and there was increased water on the plates.
-The minutes from the 9/14/22 meeting indicated the residents reported the room trays were cold.
IV. Tray line and test tray
Tray line was observed on 9/28/22 at 11:28 a.m. The dietary manager (DM) said room trays were served first and then the dining room was served. The meal was meatballs with noodles served with broccoli and a roll. The test tray was plated at 11:57 a.m. and taken on the insulated carts to the north side hallway. During transit, the roll fell off the tray and was not replaced. The tray was then placed inside the insulated cart while the resident trays were passed.
Once all the resident trays had been passed, the DM took the temperatures of the food at 12:09 p.m. The broccoli was 109 degrees fahrenheit, the noodles were 116.4 degrees fahrenheit, and the meatballs were 129.9 degrees fahrenheit.
The tray was tested for palatability at 12:11 p.m. Four surveyors tried the test tray and the consensus was the noodles were hard and took effortful chewing. The broccoli was cold and mushy with no taste and required minimal chewing. The meatballs were warm though salty. No salt or pepper was served with the meal.
V. Staff interviews
The DM was interviewed on 9/28/22 at 12:26 p.m. She said there had been complaints on food temperatures. She said most of the complaints were regarding the temperature of room trays. She said dietary staff ask the certified nurse aides to pass the trays as soon as they get to the hallway. She said dietary aides did not pass the room trays. She said she had completed room tray audits for temperature.
The DM was interviewed again on 9/29/22 at 10:10 a.m. She said plate warmers had been ordered about four months ago but had not come. She said the plate warmers were for the room trays to help with temperature. She said she would expect foods served to be at 120-130 degrees fahrenheit and said the broccoli and noodles served at the previous lunch were cold when the temperatures were taken for the test tray.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Failure to ensure infection control practices were followed for wound care
A. Professional reference
According to the Cente...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Failure to ensure infection control practices were followed for wound care
A. Professional reference
According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/8/21, retrieved from https://www.cdc.gov/handhygiene/providers/index.html, on 10/10/22, included the following recommendations: Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores.
When using alcohol-based hand sanitizer, put the product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds.
B. Observations
On 9/28/22 at 10:28 a.m. licensed practical nurse (LPN) #2 was observed performing wound care for Resident #74. The following was observed:
LPN #2 cleansed the resident's shoulder wound, which had a significant amount of serosanginous (blood and serum) drainage, with Dakins soaked gauze in a circular motion over the same area two times and threw it into a biohazard bag. She collected a new gauze soaked in Dakins and cleaned the wound in a circular motion over the same area two times and threw it into a biohazard bag. She cleansed the resident's coccyx wound with Dakins soaked gauze in circular motion over the same area two times and repeated with the same gauze two more times.
LPN #2 failed to obtain a new Dakins soaks gauze after one swipe, potentially spreading germs around the wound bed.
On 9/29/22 at 1:15 p.m. LPN #4 was observed providing Resident #56 wound care. LPN #4 cleansed the wound with Dakins soaked gauze with circular motion six times over the same area. She opened a new dressing, touched the biohazard bag and then touched the new dressing and wound with the same gloves.
At 1:45 p.m. LPN #2 was observed removing Resident #74's personal items on the bedside table and placed towel for clean supplies. She did not disinfect the table prior to laying down the towel. She was observed performing perineal care, applied a new brief and touched the clean supplies with the same gloves used to provide perineal care.
C. Staff interviews
The director of nursing (DON) and director of clinical services (DCS) were interviewed on 9/29/22 at 4:22 p.m. The DCS said the wound should be cleaned starting from the middle and working to the outside of the wound. She said if the wound had signs and symptoms of infection, a new swab of Dakins should be obtained after one swipe.
The DCS said the areas in which the supplies were placed should be disinfected prior to laying out the supplies for wound care.
She said gloves should be changed after providing care. She said the same gloves should not be used to provide perineal care and wound care.
III. Failure to ensure infection control practices were followed for medication administration
A. Observations
On 9/28/22 at 4:06 p.m. LPN #6 was observed administering medications. She dispensed a medication tablet into her bare hand and then put the medication tablet into a medication cup. She was observed entering the resident's room, offered the resident the medications, administered the medications and exited the resident's room. She did not perform hand hygiene upon entering or exiting the resident's room.
On 9/29/22 at 8:25 a.m. LPN #1 was observed knocking a pill cup over, which contained medication tablets. LPN #1 picked up the medication tablets with her bare hand, returned the medication tablets to the cup and added additional medication tablets. She then administered the cup of medications to a resident.
B. Staff interviews
LPN #3 was interviewed on 9/29/22 at 9:10 a.m. She said medication tablets should not be touched with a bare hand.
The DON and DCS were interviewed on 9/29/22 at 4:22 p.m. The DON said medications should be dispensed directly into the medication cup. She said the medication tablets should not be dispensed into the nurse's bare hand. She said that could potentially pass along germs to the resident.
Based on observations, interviews and record review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases and infections.
Specifically, the facility failed to:
-Ensure resident rooms were cleaned appropriately;
-Ensure proper infection control procedures were followed during wound care; and,
-Enusure proper infection control procedures during medication administration.
I. Failed to appropriately clean resident rooms
A. Professional reference
Centers for Disease Control and Preventions: Healthcare-Associated Infections (HAIs) 4.1 General Environmental Cleaning Techniques was reviewed on 4/21/2020 and was retrieved on 10/5/22 at https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html. The document revealed, to clean from a clean area to a dirty area to avoid spreading dirt and microorganisms. Clean low touch surfaces before high touch areas surfaces. Proceed form high areas to lower areas (top to bottom) to prevent dirt and microorganisms from dripping/falling onto surfaces below thus contaminating already cleaned surfaces. Further, clean environmental surfaces before cleaning floors. Some common high touch surfaces were sink handles, bedside tables, call bells, door knobs, light switches, bed rails, wheel chairs, and counters where medications or supplies were prepared.
B. Facility policy
The Cleaning Resident Rooms policy, revised on 10/24/18, was provided by the director of clinical services (DCS) on 9/29/22 at approximately 6:00 p.m. It read in pertinent part:
The facility staff will keep all interior areas of the building clean, presentable, safe, and health at all times. Staff will apply personal protective equipment according to standard precaution guidelines; or, apply personal protective equipment according to specific isolation in progress and follow isolation procedures.
C. Observations
On 9/28/22 at 11:02 a.m. housekeeper (HSK) #1 was observed cleaning rooms [ROOM NUMBERS] both occupied by two residents. She used the same process for both rooms and did not change her gloves between cleaning dirty surfaces or between cleaning the bathroom and the living room area shared by two residents in each room.
HSK #1 used hand sanitizer and put on a new pair of gloves before entering room [ROOM NUMBER]. She sprayed Comet 3-20 in the toilet bowl and Oxivir TB spray on the outside of the toilet seat and on the bedside tables of both residents. She used a toilet brush stored in her cleaning cart and cleaned the toilet bowl. She then emptied and replaced the trash bags under the sink and in the bathroom. She sprayed the sink basin and countertop with Oxivir TB and used a clean white cloth to wipe down the bedside table, the dressers and the sink basin first and then the sink countertop with the same cloth. She used Spic and Span 3-05 to clean the mirror with the same cloth and same gloves. She used a new clean cloth to wipe the toilet basin first, then the toilet rim and the inside and outside of the toilet seat. She flushed the toilet and placed a clean trash bag over the toilet plunger. She did not remove her gloves or apply new gloves during her cleaning process from the bathroom to the resident living room area.
HSK #1 swept the bathroom floor first and then the main living area for both residents. She placed a clean wet mop cloth on the floor and placed the mop head on the cloth. She proceeded to mop the window side of the room under the resident's bed and into the bathroom. She used the same mop cloth to mop the bathroom floor and the shared living area towards the front of the room out the door. She removed her dirty gloves and used hand sanitizer after cleaning room [ROOM NUMBER] and put new gloves on before entering room [ROOM NUMBER].
HSK #1 was observed to use the same process when cleaning room [ROOM NUMBER]. room [ROOM NUMBER] was a shared room occupied by two residents. She did not change out her gloves between the bathroom and living room area. She was observed cleaning from dirty to clean instead of clean to dirty. She cleaned the inside of the sink first and then the outside and countertop area with the same cloth. She cleaned the toilet basin first and then the toilet seat and toilet tank and handle with the same cloth.
At 1:21 p.m. HSK #2 was observed cleaning room [ROOM NUMBER]. room [ROOM NUMBER] was a single occupancy room. She used the same cleaning chemicals as HSK #1 and used the same cleaning process. HSK #2 was observed spraying the toilet basin and toilet seat with a cleaner and then sprayed the sink and bedside table of the resident. She used a sink brush she had in her cart to scrub the sink and then used a different toilet brush to scrub the toilet. When she scrubbed the toilet the water was observed to splash outside the toilet and onto the floor. HSK #2 did not change her gloves during the cleaning process and she cleaned from dirty to clean instead of clean to dirty. She was observed to move a drinking glass and reading materials off the bedside table before she wiped down the bedside table with the same gloves she used to clean the toilet. She used the same cloth to clean the sink area dirty to clean and then used the same cloth to clean the bedside table. HSK #2 did not sweep the floor because she said it was not dirty enough to sweep. She mopped the floor using the same wet mop cloth in the bathroom and the living room area. She was observed to mop the bathroom floor first and then into the living room area for the resident. She did remove her soiled gloves and use hand sanitizer after she finished cleaning the room.
D. Interviews
The housekeeping supervisor (HSKS) was interviewed on 9/29/22 at 10:30 a.m. He said there were three housekeepers and one janitor in the housekeeping department. He said he trained and supervised the housekeeping staff. He said he had a checklist of what rooms to clean and what to clean in each room. He said the housekeeping staff should use two mops for each room, one for the bathroom and one for the living room area. He said the staff should use a new pair of gloves for each room and should only use one pair of gloves for each room. He said he did not have a policy on how to clean the rooms from clean to dirty, however he thought it was common sense on how to clean a room. He said it made sense to have a process to clean from clean to dirty, however there was not a policy he was aware of or given when he started his position. He said he conducted a walk through of the facility every night to make sure the rooms looked clean. He said he understood there was a difference between a room appearing to be clean and using proper infection control procedures to not spread infections or germs.
The infection preventionist (IP) was interviewed on 9/29/22 at 11:15 a.m. She said although the housekeeping infection control process did fall under the infection preventionist to assess, she had not focused on the training of that department and expected the HSKS to provide the training. She said she would expect the housekeeping staff to change their gloves during cleaning the residents rooms between each resident's side of the room and after cleaning the bathroom. She said the housekeeping staff should change their gloves at least three times while cleaning a double occupancy room. She said she would look for a policy regarding glove wearing during the housekeeping policy and check with the HSKS to verify the policy and process.
Jun 2021
3 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 observations, record review and interviews the facility failed to ensure that residents were free from abuse, for three...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure that residents were free from abuse, for three (#124, #15 and #2) out of five residents reviewed for incidents of abuse out of 38 sample residents.
The facility failed to ensure Resident #124 had the right to be free from abuse, when a staff member of the facility took an unauthorized video/recording of the resident on a personal cell phone after the resident had fallen out of bed and was in a state of undress; and shared the eight minute video with other facility staff over social media.
The video of Resident #124 was taken during a time when personal care for the resident was needed after the resident fell out of bed. The resident was not fully clothed, had only an adult brief on and was in a compromised state, with the rest of her body being exposed. In addition, the resident had impaired cognition and was assessed just after the fall to be alert with mild confusion and oriented only to her own person.
After taking the video, the staff members shared the video with at least two other staff members over social media. The staff member denied sharing the video with any other persons, the investigation revealed other staff had received the video of Resident #124.
Resident #124 had impaired cognition and it was not believed that the resident realized the staff member was videotaping her, however; this video could be seen as demeaning and humiliating and considered emotionally abusive as the resident was taunted with profanity from the staff member who was videotaping her.
The facility failed to protect Resident #124 from abuse perpetuated by staff.
Additionally, the facility failed to recognize and prevent resident-to-resident altercations involving verbal and physical aggression between Resident #15 and #2.
I. Resident #124 being treated in a demaning and humiliating way
A. Facility policy
The Quality of Life-Dignity policy, revised February 2020, was provided by the nursing home administrator (NHA) on 6/21/21 at 1:15 p.m. It read in pertinent part: Residents are treated with dignity and respect at all times. The facility culture is one that supports and encourages humanization and individuation of residents, and honors resident choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.
-Staff promotes, maintains and protects resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
The Confidentiality of Information and Personal Privacy policy, revised October 2017, was provided by the NHA on 6/22/21 at 2:15 p.m. It read in pertinent part: Our facility will protect and safeguard resident confidentially and personal privacy .
-Release of resident information including video, audio will be handled in accordance with resident rights and privacy policy .
The Videotaping, Photographing and Other Imaging of Residents policy, revised April 2017, was provided by the NHA on 6/22/21 at 2:15 p.m. It read in pertinent part: Residents will be protected from invasion of privacy and or abuse that might occur from photographs, videotapes, digital images and recordings during resident care of other facility activities.
-Staff may not take or release images or recordings of any resident without explicit written consent.
-Transmitting unauthorized images of any resident through email, internet or social media if considered a violation of a resident's rights.
-Any image or recording taken that may be constructed as humiliating demining to a resident is considered abuse and will be reported and investigated as such.
B. Resident #124 status
Resident #124, under the age of 65, was admitted on [DATE]. According to the June 2021 computerized physicians orders (CPOs), diagnoses included anoxic brain injury, encephalopathy (brain function that was affected by infection or toxin) and delirium.
The 6/18/21 minimum data set (MDS) assessment revealed the resident had severely impaired cognition with a three out of 15 on the brief mental scale assessment. The resident's speech was often slurred and was only sometimes able to express ideas and wants and only sometimes understood verbal content, the resident needed extensive assistance from staff for all activities of daily living.
C. Record review
Review of progress notes revealed Resident #124's was discovered lying on the floor beside her bed on 6/11/21 at approximately 2:00 p.m. Certified nurse aide (CNA) #4 reported finding Resident #124 lying on the floor leaning up against the wall. The nurse on duty was notified and the resident was assessed for injuries and helped back to bed.
Nursing note dated 6/11/2021 at 9:13 p.m. read in part: at 2:00 p.m. CNA found Resident #124 on the floor at the bedside .The registered nurse (RN) assessed the resident and assisted the resident back to bed, no head injury or physical injury involved.Resident could not explain how she fell. Mild confusion was noted, the resident is alert and oriented only to person .
It was later that the facility discovered the CNA #4 had taken a video of the resident as she laid on the floor in nothing but an adult diaper and sent the video by Facebook messenger to two other CNAs who worked in the facility. Once this was discovered, CNA #4 was suspended and an investigation was initiated.
-CNA #4 no longer is employed with the facility, see NHA interview below.
D. Facility investigative report
The facility investigation report revealed the CNA #4 said she walked into the room; the resident was on the floor so she took a video to share with staff to help understand how this happened.
The resident was not interviewed about the incident until 6/15/21, four days after the event and she was not able to give details of the incident. The UM reported that the resident showed no signs of distress and felt safe.
The UM did not specifically ask the resident if she was ever videotaped by a staff member.
CNA#3 said CNA #4 sent the video of Resident #124 to her by Facebook messenger. The video opened with Resident #124 sitting on the floor leaning against the bed. The resident was unclothed. CNA #4 was heard saying how the F*** did you end up there and then told the resident you know you are not supposed to get up on your own. CNA #3 said she reported the video to the human resources manager; and was not aware of any other videos circulating around.
CNA #5 said she had received a video of Resident #124 through Facebook messenger from CNA #4 she immediately deleted the video and did not comment on the video.
There was no indication if the facility investigator asked the staff if anyone else was included in the messenger thread or if they saw this video in any general Facebook threads.
The investigation report contained a transcript of the video. Per the director of nursing's (DON) account of the video. The video showed Resident #124 sitting on the floor leaning against the wall in nothing but an incontinent brief. In the audio portion of the video CNA #4 could be heard saying Help me understand how the F*** this sh** happens. How did you get out of bed? Resident #124 responded I fell out of bed., the rest of what the resident said was not understandable. CNA #4 responded You're not supposed to! Resident #124 said I know it., the rest was not understandable. The video lasted a full eight minutes before ending.
E. Resident interview
Resident #124 was interviewed on 6/21/21 at 10:22 a.m. Resident #124 observed lying in bed. The resident was unable to remember falling or anyone taking her picture recently and had no current concerns about staff.
F. Staff interviews
The NHA was interviewed on 6/21/21 at 11:30 a.m. The NHA said the resident had impaired cognition and based on the video he did not believe the resident knew she was being videotaped. When the resident was interviewed about the incident, she was unable to focus on the questions being asked. The staff who took the video CNA #4 was suspended immediately upon discovery that she had taken an unauthorized video of Resident #124. An investigation was initiated immediately. Based on investigative findings CNA #4 was separated from the facility for gross misconduct and failure to follow facility policy.
The DON was interviewed on 6/21/21 at 11:32 p.m. The DON said after this incident they provided staff education on customer services and the expectation to treat all residents with dignity and respect. No staff were to take pictures of residents during care or use their personal phones to take resident pictures of videos. The only time any staff were permitted to take a resident picture was with signed and verbal consent form the resident, or the resident legal representative when the resident had impaired decision managing ability.
CNA #5 was interviewed on 6/22/21 at 12:05 p.m. CNA #5 said staff were to ensure resident privacy at all times. Staff were never permitted to take a picture of staff particularly when they were exposed or not wearing clothing. It was not ok for staff to share pictures of residents on their personal phones or over social media. CNA #5 said if staff had knowledge of such activity, they were to report the activity to management immediately.
The activities director (AD) was interviewed on 6/22/21 at 12:20 p.m. The AD said staff were only permitted to take pictures of a resident with a signed consent form the resident or the resident's guardian/responsible party. Residents were always free to change their mind and refuse to permit a picture from being taken so staff were to ask for verbal consent for each photo. Staff were never permitted to take pictures of residents during care or when a resident was not fully dressed. Staff were never permitted to take a photo on their personal phones; the facility had a designated camera to take photos of residents during recreational programming.
Licensed practical nurse (LPN) #5 was interviewed on 6/22/21 at 12:39 p.m. LPN #5 said staff were not permitted to take any picture of a resident without consent and were never to take a resident's picture on their personal phones for any reason.
The NHA was interviewed on 6/22/21 at 5:05 p.m. The NHA said CNA #4 said she would delete the video she took of the resident form her phone and Facebook messenger account, as did the other two CNA who received the video in Facebook messenger. The only known video of the resident was being held by the facility legal department.
II. Resident #15 and Resident #2
A. Facility policy
The Abuse policy, revised 10/28/2020, was provided by the nursing home administration (NHA) on 6/16/21 at 9:30 a.m. The policy read in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents .
-Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion.
-Standards: Providing a safe environment for the residents is one of the most basic and essential duties of our facility.
-Resident abuse is defined as the willful infliction of injury .Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability.
-If a resident experiences a behavior change resulting in aggression toward other residents, the facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse.
B. Resident to resident altercation between Resident #15 and #2
Facility reported incident investigation dated 5/15/21 for an allegation of resident-to-resident physical abuse was provided by the director of nursing (DON) on 6/21/21 at 9:13 a.m.
The investigation report revealed Resident #15 was sitting in her electric wheelchair by the activities sponsored store talking to activities assistant (AA) #1; Resident #2 was a few feet away trying to get AA #1's attention by calling out hey, hey. AA #1 asked Resident #2 to wait his turn but he continued to try to get AA #1's. Resident #15 then said to AA #1 that Resident #2 only had a 5th grade education. Resident #2 heard the comment and rolled his wheelchair over to Resident #15 and punched Resident #15 closed fist in the left shoulder.
Facility Investigative interviews
Resident #15 told the investigator she was sitting at the store talking to AA #1, when Resident #2 started to holler at AA #1. Resident #15 said she told AA #1 do not worry Resident #2 only had a 5th grade education; then Resident #2 came closer. Resident #15 said she told AA #1 Resident #2 needed to mind his own business and then he hit her.
Resident #2, was unable to express what occurred; and just said, Oh baby!.
AA #1 said Resident #2 was in the hallway yelling at another resident ' Resident #15 told Resident #2 to mind his own business and Resident #2 went over to Resident #15 yelling what, what and proceeded closer and punched Resident #15 in the left arm with a closed fist.
Licensed practical nurse (LPN) #6 said Resident #15 was in the hall by the activities store; she did not see what happened but heard Resident #15 say don't you fu**ing touch me again and continued to say other insulting words to Resident #2. LPN and other staff intervened and Resident #15 and #2 were separated.
The social services director (SSD) did not see the event but talked to Resident #15 after the event. The SSD's interview did not document what Resident #15 told her or Resident #25's demonor or behavior during the interview.
C. Residents #15
1.Resident interview
Resident #15 was interviewed on 6/16/21 at 10:50 a.m. Resident #15 said Resident #2 punched me yesterday. Resident #15 said Resident #2 was in the hall making weird noises; I leaned over to talk to AA#1 and told her I don't think he has more than a 5th grade education. Resident #2 yelled out what did you say? and he rolled over and punched me in the arm. Resident #15 pointed to her left upper arm and said it still hurts. She did not have any bruises in the area of her arm she identified as where Resident #2 hit her. Resident #15 was not sorry for her comment about Resident #2 and was surprised he could hear her form where he was sitting. Resident #15 said Resident #2 was very abusive and he went around punching people when he got angry with them.
2. Resident status
Resident #15, under the age [AGE], was admitted on [DATE]. According to the June 2021 computerized physician orders (CPO), diagnoses included borderline personality disorder, diabetes mellitus and heart disease.
The 3/31/21 minimum data set (MDS) assessment revealed the resident had intact cognition with a score of 15 out of 15 on the brief interview for mental status (BIMS); and exhibited no behaviors during the time of the assessment. The resident needed one-person assistance with transfers and set up assistance with other activities of daily living; and used a power wheelchair to get around the community.
3. Record review
Resident #15's comprehensive care plan revealed a care focus for borderline personality disorder, last revised 6/2/21. The care focus indicated the resident was resistant to care and that she called certain staff members inappropriate names as she passed them in the halls.
The care plan failed to document a specific care focus for negative behaviors directed towards other residents such as derogatory negative comments which may have a negative effect on the other person's emotional state and/or lead to a resident to resident altercation.
Progress notes revealed the facility was aware of the resident's tendency to make inappropriate and negative comments towards peers and the need to intervene and redirect such behaviors. Progress notes revealed:
-Activity note dated 3/30/21 at 11:48 a.m., read in part: .Mood and behaviors that affected participation: At times tend to get angry at peers, or yell at peers. Needs redirection from inappropriate language being used at activity staff .
-Psychosocial note 4/16/21 at 2:25 p.m., read in part: Resident #15 was leaving her room today when she made judgmental statements to two residents. Social Services offered to transfer her to somewhere she would be more comfortable and she declined.
-Incident note dated 6/15/21 at 5:36 p.m., read in part: Per report at approximately 2:00 p.m. Resident #15 was talking to an employee in activities during activities store hours (by the activity store). Per report, Resident #2 approached her aggressively asking 'what?' assuming she was talking about him. Resident stated she did not reply to him but he approached her and punched her on her left upper arm with a closed fist. Resident currently not complaining of pain to the area, skin intact with no discoloration, intact baseline range of motion. Educated res on safety, de-escalation incases of arguments and conflict resolution, res verbalized understanding of teaching. Will continue to monitor this resident.
-Interdisciplinary team (IDT) risk management note dated 6/17/21 10:36 a.m., read in part: Date of incident: 6/15/21; type of incident: physical aggression received; root cause: Resident #15 made a derogatory statement to a staff member about another resident within earshot and it upset that resident.
Treatment required: none indicated. Interventions put into place: Resident #15 is alert and oriented and at times knowingly makes hurtful comments to and/or about other residents; re-educated Resident #15 about not making these sort of statements that hurt others.
D. Resident #2
1. Resident interview
Resident #2 was interviewed on 6/21/21 at 9:10 a.m. Resident #2 was unable to explain any resident-to-resident altercations he was involved in. When asked how he was getting along with others Resident #2 said yeah, yeah, and some other non-understandable phrases.
2. Resident status
Resident #2, under the age of 65, was admitted on [DATE]. According to the June 2021 CPO, diagnoses included aphasia (difficulty expressing verbal communication) following a stroke, anxiety disorder and vascular dementia with behavioral disturbance.
The 4/1/21 MDS assessment revealed the resident had severely impaired cognition as evidenced by a score of three out of 15 on the BIMS. The resident had difficulty communicating some works or finishing thoughts and missed some parts or intent of messages but comprehended most conversations. The resident did not reject care or exhibit any behaviors during the time of the assessment. The resident needed extensive assistance from staff to complete activities of daily living but was able to move about the community in a manual wheelchair.
3. Record review
-Resident #2's comprehensive care plan revealed a care focus for behavior, last revised on 3/10/21. The care focus indicated:
-Resident #2 had behavior challenges related to anger issues. Resident #2 was easily riled and exhibited shakiness, crying and could become verbally and physically aggressive.
-Resident #2 had potential to be verbally aggressive towards other residents and staff related to ineffective coping skills and poor impulse control.
-Resident #2 had potential to be physically aggressive towards other residents and staff members related to anger, depression, a history of harm to others, and poor impulse control.
-Resident #2 displays aggressive behaviors of kicking toward staff and other residents; grabbing staff arm; teasing, placing himself to block resident/visitor/staff way to get through. Resident #2 has verbal behaviors such as cussing and yelling at staff and other residents.
Care planned interventions included, in part:
-Give medication as needed;
-Behavior monitoring for mood stabilizer medication;
-Review behaviors/interventions and alternate therapies attempted and their effectiveness;
-Minimize potential for Resident #2's disruptive behaviors, such as yelling, by offering tasks which divert attention;
-When the resident becomes agitated, intervene before agitation escalates;
-Guide away from sources of distress;
-Engage calmly in conversation;
-Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior; and,
-Encourage seeking out a staff member when agitated .
Progress notes from 10/8/2020 through 6/17/21 were reviewed. The notes revealed Resident #2 had a number of incidents involving both verbal and physical altercation with other residents. Additionally, the facility had documented the incidents and intervention assessments (see a partial list of current intervention to prevent Resident #2 from becoming aggressive towards other residents as documented above). The latest facility reported incident notes read:
-Incident note dated 6/15/21 at 5:58 p.m., it read: Per report at approximately 2:00 p.m., Resident #15 was talking to an employee in activities during activities store hours (by the activity store). Per report, Resident #2 approached Resident #15 aggressively asked 'what?' and punched her on the left upper arm with a closed left hand fist. Resident #2 declined to give his side of the incident story. Residents were assessed and no apparent injuries were noted. Resident #2 was not complaining of any pain, skin intact with no discoloration .educated Resident #2 on safety, de-escalation of arguments and conflict resolution.
-IDT risk management review note dated 6/17/21 at 10:18 a.m., read: Date of incident: 6/15/21; type of incident: physical aggression. Root cause: overstimulation related to outside construction; inability to go to a quiet place; and poor impulse control. Treatment required: none. Interventions put into place: monitor for signs of increased agitation and encourage going to a quiet place if noted.
The facticity investigation did not document any findings for environmental overstimulation. See incident summary above); and the IDT did not document the Resident #2's aggressive response in relationship to Resident #15's comments about Resident #2's cognitive abilities and how that may have affected Resident #2 mood and emotional state.
E. Staff interviews
The NHA was interviewed on 6/21/21 at 9:30 a.m. the NHA said he expected staff to intervene immediately when any resident showed aggression towards another resident. Residents were to be separated and monitored for any additional signs of aggression.
The DON was interviewed on 6/21/21 at 10:10 a.m. The DON said as soon as a resident to resident altercation was observed or identified, staff were expected to intervene and redirect the residents, ensure safety, check for injury and treat as necessary, and educate the resident on acceptable behavior as appropriate. Behavior was assessed and the resident's care plans were updated immediately if new interventions were necessary.
AA #1 was interviewed on 6/22/21 at 12:50 p.m. The AA said she was with Resident #15 at the facility store on 6/15/21 at approximately 1:45 p.m. Resident #2 was a few feet away in the hall. Resident #2 was yelling at another female resident also in the hall. Resident #15 yelled to Resident #2 to mind his own business and commented that he only had a 5th grade education. Resident #2 responded to Resident #15 saying what?!; Resident #15 responded to Resident #2 by repeating mind your own business. Resident #2 rolled his wheelchair to Resident #15 and punched her on the side of her left arm.
The punch made a smacking sound as his closed fist hit Resident #15's arm. AA #1 demonstrated by making a fist and hitting it into her palm and said it sounded like this (there was a loud audible smacking sound). Resident #15 responded by saying, hey don't touch me! AA #1 said it happened so quickly that she did not have time to prevent Resident #2 from punching Resident #15 but she reacted as quickly as possible to intervene and prevent any further physical altercation between the two residents.
Other staff also intervened and helped to separate Resident #2 and #15. AA #1 said she could tell that Resident #2 was upset over Resident #15's negative comments because Resident #15's face showed anger and his body was very tense. Staff took Resident #2 outside and he was able to calm down. Since the altercation, Resident #15 and #2 had been able to stay away and avoid contact with each other.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to ensure it was free of a medication error rate of five ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to ensure it was free of a medication error rate of five percent (%) or less on one of two units.
Specifically, the medication administration observation error rate was 7.69%, or two errors out of 26 opportunities for error for Resident #46. Lantus insulin and Lasix medications were not administered during medication observation times.
Findings include:
I. Facility policy
The Medication Administration Policy revised in April 2019, was provided by the corporate consultant (CC) on 6/22/21 at 3:30 p.m., it read in pertinent part; Medications are administered in a safe and timely manner, and as prescribed. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: Enhancing optimal therapeutic effect of the medication, preventing potential medication or food interactions, honor resident choices and preferences, consistent with his or her care plan. Medication errors are documented, reported, and reviewed by the quality assurance performance improvement (QAPI).
-On 6/21/21 at 4:10 p.m. documentation was requested from the corporate consultant (CC) for the missed medication policy and no other documentation had been provided.
II. Observations and interviews
Licensed practical nurse (LPN) #1 was observed on 6/17/21 at 4:20 p.m. to administer medications for Resident #46. LPN looked at the order for lantus insulin 40 units due at four p.m.and she could not find the medication in the medication cart. She looked in the medication refrigerator to see if there was any extra insulin and there was none.
LPN reordered the lantus insulin from the computer and said she would call the pharmacy before the end of her shift to check on the status and write a progress note. She moved on to the next medication which was lasix 40 milligrams (ml) due between four and seven p.m., LPN could not find the lasix medication so she reordered that medication through the computer. She said she would call the pharmacy and write a progress note for lasix. She proceeded to take all the other medications available to the resident to administer. She told Resident #46 the medication lasix and lantus were not available and she would give the medication when it arrives from the pharmacy. She took the resident's blood glucose which read 162.
The June 2021 computerized physician orders (CPOs) for Resident #46 revealed the following orders: Lantus insulin 40 units subcutaneously two times a day. Hold insulin when blood glucose reading was less than 100. Order start date was 12/2/2020. Lasix 40 two times a day. Order start date was 10/12/2020.
III. Resident #46 status
Resident #46, age [AGE], was admitted on [DATE]. According to the June 2021 computerized physician orders (CPO), diagnoses included diabetes, seizure disorder and anxiety.
The 5/11/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required two persons extensive assistance with two people for transfers, bed mobility, toileting, dressing and limited assistance of one person for hygiene. He was set up for meals. No rejection of care was documented. He was on injectable medications daily.
IV. Record review
The June 2021 medication administration record (MAR) was reviewed on 6/21/21 at 9:30 a.m. for Resident #46 and revealed; lasix was checked as given on 6/17/21 by licensed practical nurse (LPN) #1 and lantus was checked by LPN #1 on 6/17/21 with a nine to indicate the medication was not available.
The medication administration audit report provided by the corporate consultant (CC) on 6/21/21 at 12:45 p.m. revealed:
-Lasix 40 mg was signed by LPN #1 on 6/17/21 at 6:43 p.m. and;
-Lantus 40 units were signed by LPN #1 on 6/17/21 at 7:52 p.m. (three hours and 52 minutes late).
Review of the 6/17/21 at 7:52 p.m. nurse notes on 6/21/21 at 9:35 a.m. revealed Resident was out of lantus insulin, and the medication was reordered from the pharmacy.
Record review revealed no communication with the physician on medications being given late or not administered at all.
V. Interviews
LPN #2 was interviewed on 6/17/21 at 4:52 p.m. she said medications were reordered when there were a few days left of the medication. She said if no medication was available to administer, a progress note was written and the physician was notified of the missed medications or late medications.
The director of nurses (DON) was interviewed on 6/21/21 at 8:45 a.m. she said when a medication was refilled a few days prior to the medication running out. She said medication was refilled within 72 hours. For new admissions the medication was delivered the same day. She said when medication was needed from the emergency kit (ekit) for insulin the nurse signed the medication out, faxed it to the pharmacy and the pharmacy restocked the ekit.
There was no insulin stored in the omnicell (medication storage safe). She said when a medication was missed or late the physician was notified and the nurse wrote a progress note and the resident was watched for any adverse reaction from the missed medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to maintain an infection program designed to provide a sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to maintain an infection program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as coronavirus (COVID-19) in one of two units.
Specifically the facility failed to ensure the use of proper personal protective equipment (PPE) in resident isolation rooms to include room [ROOM NUMBER], #33, #34, #35, #58, #59, room.
I. Professional reference
According to CDC guidance, Responding to Coronavirus (COVID-19) in Nursing Homes Considerations for the Public Health Response to COVID-19 in Nursing Homes, updated 4/30/2020, retrieved online 6/23/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html Even as nursing homes resume normal practices and begin relaxing restrictions, nursing homes must sustain core infection control (IPC) practices and remain vigilant for SARS-CoV-2 infection among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalizations, and death.
-Residents with confirmed SARS-CoV-2 infection who have not met criteria for discontinuation of Transmission-Based Precautions should be placed in the designated COVID-19 care unit.
In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission.
-All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown.
II. Facility policy
The Personal Protective Equipment policy, revised in October 2018, was provided by the director of nurses on 6/21/21 at 3:00 p.m., it read in pertinent part; Personal protective equipment appropriate to specific task requirements was available at all times. PPE provided to our personnel includes but not necessarily limited to: gowns, gloves, masks and eyewear. A supply of protective clothing and equipment was maintained at each nurses station. PPE required for transmission-based precautions was maintained outside and inside the residents room as needed. Training on the proper donning, use and disposal of PPE was provided upon orientation and at regular intervals. Employees who fail to use PPE when indicated may be disciplined in accordance with personal policies.
The Coronavirus (COVID-19) Prevention, Response and Testing policy, developed 9/2/2020, was provided by the corporate consultant (CC) on 6/21/21 at 3:00 p.m., it read in pertinent part; The facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat and prevent the spread of the virus and implement COVID-19 testing in accordance with the Center for Medicare and Medicaid (CMS) regulations. Educate staff on proper use of PPE and application of standard, contact, droplet, and airborne precautions, including eye protection. Promote easy and correct use of PPE to be available immediately outside the residents room.
III.Observations
Certified nurse aide (CNA) #1 was observed on 6/16/21 at 9:05 a.m. to answer the call light for isolation room [ROOM NUMBER]. There was an isolation cart outside the room and the isolation sign that said contact droplet precautions laid on the floor. CNA #1 had on a surgical mask and entered the room. She took out the used food tray for the resident in bed A who was on isolation precautions and put it in the food cart in the hallway. She failed to don any other personal protective equipment (PPE).
Licensed practical nurse (LPN) #4 was observed on 6/16/21 at 9:24 a.m. to wear a surgical mask, he donned a gown and gloves and failed to wear eye protection. He entered the isolation room [ROOM NUMBER] and gave the resident in bed A who was in isolation his inhaled medication. LPN #4 left the room, set the residents used inhaler on the handrail outside of the room and doffed the PPE gear. He saw the isolation sign on the floor, picked it up and hung it on the residents door.
On 6/16/21 at 12:27 p.m., lunch services were observed. Certified nurse aide (CNA) #6 was observed entering room [ROOM NUMBER] to deliver and set up the resident's meal. The CNA performed hand hygiene and put on a yellow protective gown before entering but did not put on an N95 mask or any type of eye protection. There was a sign on the door indicating the resident was on droplet and contact precautions and full personal protective equipment was required for entry to the resident room.
CNA #6 next entered room [ROOM NUMBER] and #35. Both resident rooms had a sign on the door indicating a need for full personal protective equipment for both contact and droplet precautions. The CNA failed to change into an N95 mask or put on eye protection for entry and care for the residents in either room.
CNA #7 was observed entering room [ROOM NUMBER] to deliver and set up the resident's lunch. There was a sign on the door indicating a need for full personal protective equipment. The CNA failed to put on a protective gown or eye protection when entering the room.
The resident concierge (RC) was observed on 6/16/21 at 12:34 p.m. to wear a surgical mask and enter the isolation room [ROOM NUMBER]. She stood in the isolation room for a minute with just a surgical mask on then left the room, she entered the room again wearing just a surgical mask to assist the resident in bed B who was not in isolation.
Unit manager (UM) was observed on 6/16/21 at 4:30 p.m. to bring a box of new N-95 masks to the south unit and stock the isolation cart outside of room [ROOM NUMBER].
On 6/21/21 at 3:45 p.m. CNA #8 and CNA #9 were observed providing routine care for residents. Both CNA's entered room [ROOM NUMBER] and then room [ROOM NUMBER] both residents were on contact and droplet precautions. Neither CNA put on an N95 mask or eye protection while providing incontinent care for the resident.
IV. Interviews
CNA #6 was interviewed on 6/16/21 at 12:32 p.m. CNA #6 said the residents in rooms numbered #34, #35, #58 and #59 were in isolation for COVID precautions because they were newly admitted to the facility; she did not know if staff were required to follow both precaution signs and did not think she had to wear eye protection. The CNA said she always kept her surgical mask on and put on a gown when entering a room where a resident was in isolation for COVID-19 precautions.
The assistant director of nursing (ADON) was interviewed on 6/16/21 at 12:40 p.m. The ADON said the residents in room numbers #32, #33, #35, #58 and #59 were newly admitted to the facility and were on a 14-day isolation as a precaution for possible COVID-19 exposure. Staff were required to put on full personal protective equipment when entering the resident rooms for any reason. This included an N95 mask, a gown, eye protection and gloves.
LPN #3 was interviewed on 6/16/21 at 3:55 p.m. she said full PPE with an N95 mask, gown gloves and eyewear had to be worn in an isolation room. She said one resident in room [ROOM NUMBER] was in isolation but they had to wear the full PPE gear for both residents in the room. She said residents that were not vaccinated after readmission and had to be isolated for 11 days.
Certified nurse aide (CNA) #2 was interviewed on 6/16/21 at 4:05 p.m. she said she had to wear her N95 mask, gown, gloves and eyewear in the isolation rooms.
The director of nurses (DON) was interviewed on 6/16/21 at 3:15 p.m. she said expected the staff to wear full PPE in an isolation room to include an N95 mask, gown, gloves and eyewear for the entire room. She said the PPE protected both residents from prolonged exposure of the COVID-19 virus. She said resident in room [ROOM NUMBER] bed A was a readmission who was not vaccinated and bed B resident in room [ROOM NUMBER] was a resident who was vaccinated. She said both residents refused to move rooms.
The director of nurses (DON) was interviewed again on 6/22/21 at 10:30 a.m., she said the facility started on the spot training on 6/16/21 for donning and doffing PPE in isolation rooms for all staff.
Follow up training was provided by the unit manager (UM) on 6/22/21 at 3:00 p.m. The huddle topic on 6/16/21 revealed the steps on how to don and doff PPE. There were signatures of 43 staff members.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 36% turnover. Below Colorado's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 3 harm violation(s). Review inspection reports carefully.
- • 40 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade F (21/100). Below average facility with significant concerns.
Bottom line: Trust Score of 21/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is University Heights's CMS Rating?
CMS assigns UNIVERSITY HEIGHTS CARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Colorado, 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 University Heights Staffed?
CMS rates UNIVERSITY HEIGHTS CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 36%, compared to the Colorado average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at University Heights?
State health inspectors documented 40 deficiencies at UNIVERSITY HEIGHTS CARE CENTER during 2021 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 36 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates University Heights?
UNIVERSITY HEIGHTS CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by VIVAGE SENIOR LIVING, a chain that manages multiple nursing homes. With 105 certified beds and approximately 88 residents (about 84% occupancy), it is a mid-sized facility located in AURORA, Colorado.
How Does University Heights Compare to Other Colorado Nursing Homes?
Compared to the 100 nursing homes in Colorado, UNIVERSITY HEIGHTS CARE CENTER's overall rating (2 stars) is below the state average of 3.1, staff turnover (36%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting University Heights?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is University Heights Safe?
Based on CMS inspection data, UNIVERSITY HEIGHTS CARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Colorado. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at University Heights Stick Around?
UNIVERSITY HEIGHTS CARE CENTER has a staff turnover rate of 36%, which is about average for Colorado 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 University Heights Ever Fined?
UNIVERSITY HEIGHTS CARE CENTER has been fined $9,315 across 1 penalty action. This is below the Colorado average of $33,172. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is University Heights on Any Federal Watch List?
UNIVERSITY HEIGHTS CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.