RIVER VALLEY REHABILITATION AND HEALTHCARE CENTER
For profit - Individual
60 Beds
CENTENNIAL HEALTHCARE
Data: November 2025
Trust Grade
13/100
#197 of 208 in CO
Photo by River Valley Rehabilitation and Healthcare Center
Photo by River Valley Rehabilitation and Healthcare Center
Photo by Google Street View
1 / 5 photos
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
River Valley Rehabilitation and Healthcare Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #197 out of 208 facilities in Colorado, placing them in the bottom half of the state, and #3 out of 3 in Rio Grande County, meaning there are no better local options. Although the facility is improving, decreasing from 11 issues in 2024 to 1 in 2025, they still report a high turnover rate of 57%, which is concerning. Specific incidents include a resident suffering a fractured hip due to improper supervision during transfers and another resident requiring emergency care after multiple falls. While staffing and RN coverage are average, the facility has serious deficiencies, including a failure to maintain proper food safety standards and ensure staff competency in care techniques. Families should weigh these strengths and weaknesses carefully when considering this home for their loved ones.
- Trust Score
- F
- In Colorado
- #197/208
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 57% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $14,768 in fines. Higher than 93% of Colorado facilities. Major compliance failures.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for Colorado. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
13/100
Bottom 6%
Review needed
11 → 1 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Colorado average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 57%
11pts above Colorado avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $14,768
Below median ($33,413)
Minor penalties assessed
Chain: CENTENNIAL HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (57%)
9 points above Colorado average of 48%
The Ugly 29 deficiencies on record
1 actual harm
Apr 2025
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and the main dining room.
Specifically, the facility fai...
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Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and the main dining room.
Specifically, the facility failed to:
-Ensure food was labeled, dated and discarded in a timely manner; and
-Ensure the refrigerator and hot cocoa machine was cleaned regularly.
I. Failed to ensure food was labeled, dated and disposed of timely
A. Professional reference
The Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 4/2/25 read. in pertinent part,
A date marking system that meets the criteria 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; 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 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. (Chapter 3-29)
B. Observations and interviews
On 4/2/25 at 12:40 p.m., during the kitchen tour, the following items were found in the main kitchen refrigerator without an open date:
-An open container of coleslaw;
-A sealed bag of unknown meat;
-A plastic container of peaches;
-A large sealed storage bag with a red sauce;
-A sealed storage bag with a half an avocado;
-A large sealed storage bag of celery;
-A plastic container of dressing; and
-Two packages of muffins.
Also observed in the refrigerator were two items that were expired:
-A package of unknown meat, dated 3/7/25; and,
-A sealed bag of lettuce, dated 3/14/25.
Additionally, the refrigerator had two large pork loins on the bottom of the refrigerator not in a covered pan.
The dietary manager (DM) said the staff had not dated the identified items when they were opened. She said food could only be stored for five days. She said the meat and the lettuce needed should have been thrown out. The DM said the pork loins should have been in a pan with a cover.
II. Failed to ensure a sanitary kitchen
A. Professional reference
The Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 4/2/25 read in pertinent part,
Equipmenet 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. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (Chapter 4-20)
B. Observations and interview
On 4/2/25 at 12:40 p.m. an unknown substance, yellow in color and powdery around the edges, was found covering a large area on the bottom of the refrigerator in the main kitchen. The hot cocoa machine in the main dining room had debris on it. The tube that dispensed the cocoa was dirty with specks of cocoa all over the end of the tube touched mugs and cups. There was a large amount of loose cocoa inside of the machine. The DM said the refrigerator and the cocoa machine should have been cleaned.
III. Staff interviews
The DM was interviewed on 4/2/25 at 12:50 p.m. The DM said the food should be dated to make sure the food was not spoiled and safe for consumption. The DM said the pork loin should have been in a pan with a cover to prevent leaking and cross contamination. The DM said the refrigerator and hot cocoa machine should have been cleaned daily to prevent food borne illnesses.
The nursing home administrator (NHA) was interviewed on 4/2/25 at 4:00 p.m. She said food should be dated to ensure the food was thrown out after five days. She said the expired food needed to be discarded for the protection of the residents. She said the pork loins should have been in a covered pan to prevent cross-contamination. She said the refrigerator and cocoa machine should have been cleaned daily. She said she would be working with the new DM to support her in the changes she would be making.
Dec 2024
11 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and explo...
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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 that all residents were free from abuse, neglect, and exploitation for one (#53) of three residents reviewed for abuse out of 41 sample residents.
Specifically, the facility failed to protect Resident #53 from verbal abuse by certified nurse aide (CNA) #7.
Findings include:
I. Facility policy and procedure
The Abuse Prevention policy, revised March 2018, was provided by the nursing home administrator (NHA) on 12/17/24 at 3:10 p.m. It read in pertinent part,
The physician and staff will help identify risk factors for abuse in the facility, for example, issues related to staff knowledge and skill, or performance that might affect resident care.
The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.
The management and staff will address situations of suspected or identified abuse and report them in a timely manner
to appropriate agencies, consistent with applicable laws and regulations.
II. Facility investigation of the abuse allegation involving Resident #53 and CNA #7 on 8/8/24
The facility's investigation of the allegation of physical abuse between Resident #53 and CNA #7 on 8/8/24 documented the following:
The investigation report read that after a shower Resident #53 was observed crying in the sunroom. The facility started an investigation immediately and the police were notified 8/8/24 at 11:00 a.m. The investigation report documented Resident #53 denied verbal or physical abuse occurred and was hesitant to answer questions asked by the police investigator.
The investigation report, dated 8/8/24, documented that licensed practical nurse (LPN) #2 heard CNA #7 tell Resident #53 Stop (expletive word) crying. LPN #2 reported Resident #53 was observed crying during the occurrence. CNA #8 reported she observed CNA #7 make Resident #53 take a shower when Resident #53 did not want a shower and she heard CNA #7 tell Resident #53, (Expletive word) you, you piece of (expletive word) and
Do not start with me.
On 8/8/24 the facility interviewed Resident #53's previous roommate. The documentation revealed the roommate reported he heard CNA #7 joking around, exchanging words, and hollering between CNA #7 and Resident #53. The roommate reported he heard CNA #7 tell Resident #53 he would take a shower regardless and the roommate said he was afraid that CNA #7 might cut Resident #53 while helping him shave for reporting his feelings.
On 8/8/24 the facility interviewed six current residents and two family members of residents in the facility. The documentation revealed no residents or family members reported they had been treated roughly or rudely or yelled at by staff or others. None of the residents or the family members reported feeling afraid because of the way some other resident was treated.
On 8/8/24 the facility interviewed two current employees. The documentation reviewed the employees had no concerns about the care provided by CNA #7.
On 8/8/24 the facility completed 14 random skin assessments of current residents in the facility. There were no concerns identified during the random skin assessments.
CNA #7 was placed on suspension on 8/8/24 pending the facility's investigation of the incident and terminated on 8/16/24.
The facility required all staff to complete abuse training, prevention and reporting during new hire orientation and staff received ongoing education on abuse prevention at staff meetings and individually as needed.
Resident #53 was monitored following the incident for any behaviors related to the incident.
III. Resident #53
A. Resident status
Resident #53, age [AGE], was admitted on [DATE]. According to the December 2024 computerized physician's orders
(CPO), diagnoses included right side paralysis, history of stroke and depression.
The 10/18/24 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of ten out of 15. The resident was dependent on staff for transfers, showers, and toileting and required assistance from staff for showers or bathing. The resident did not walk and used a manual wheelchair to get around the unit with assistance from staff.
The assessment documented the resident had no verbal, physical, or behavioral symptoms directed towards others. The resident had no history of rejecting care.
B. Resident interview
Resident #53 was interviewed on 12/17/24 at 9:25 a.m. Resident #53 said that CNA #7 forced him to take a shower when he declined. He said CNA #7 yelled at him and made him feel afraid and sad and tearful after the shower.
Resident #53 said CNA #7 was also his son. and he no longer worked at the facility. Resident #53 said when his son came to visit they spent time together in the common area sunroom or in a table area at the end of a hallway. Resident #53 said his son did not yell at him during the visits and he enjoyed the visitations with his son.
C. Record review
The nurse progress note dated 8/8/24 at 4:54 p.m. documented the NHA observed Resident #53 crying in the front lobby of the facility and the NHA initiated an investigation.
IV. Staff interviews
-LPN #2 and CNA #8 (who witnessed the incident on 8/8/24) were not available for interviews during the survey.
CNA #3 was interviewed 12/17/24 at 9:25 a.m. CNA #3 said she was familiar with Resident #53 and knew about the incident between Resident #53 and CNA #7. CNA #3 said she had not noticed Resident #53 with any mood or behavior changes following the incident. CNA #3 said she had received education on abuse prevention during her CNA school and from the facility when she was hired. CNA #3 said she had no concerns about abuse of residents or staff in the facility.
The NHA was interviewed on 12/17/24 at 10:50 a.m. The NHA said on 8/8/24 she noticed Resident #53 crying as he sat in the sunroom area. The NHA said she followed facility policy and initiated an investigation. The NHA said Resident #53 denied verbal abuse but two staff members witnessed and reported the verbal abuse toward Resident #53. The NHA said CNA #7 was suspended immediately on 8/8/24 and terminated on 8/16/24.
The NHA said the facility monitored Resident #53 for signs or symptoms of post-traumatic stress disorder (PTSD) following the incident and no changes in the resident occurred. The NHA said after the incident, the facility completed interviews with staff and other residents and completed skin assessments on other residents CNA #7 care for. The NHA said there were no concerns identified.
The NHA said staff received education on abuse prevention during new-hire orientation and at other times, such as during staff meetings or morning huddle meetings, and as needed. The NHA said staff were educated to identify and report concerns of abuse or neglect immediately.
The NHA said CNA #7 was also the son of Resident #53. She said Resident #53 wanted his son to continue to be allowed to visit him periodically in the facility. The NHA said the facility had a safety plan for visitation that required visits between Resident #53 and his son (CNA #7) to be in common areas and in the line of sight of other staff members. The NHA said there had been no concerns of abuse identified or changes to the resident's mood after visits with his son.
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 observations, record review and interviews, the facility to ensure for one (#5) of three residents reviewed for assista...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility to ensure for one (#5) of three residents reviewed for assistance with activities of daily living (ADL) out of 41 sample residents received the appropriate treatment and services to maintain or improve his or her abilities.
Specifically, the facility failed to:
-Ensure Resident #5 was provided with the appropriate level of assistance for positioning and transfers; and,
-Ensure Resident #5's care plan was updated with the appropriate level of staff assistance for transfers per therapy discharge instructions.
Findings include:
I. Resident #5
A. Resident status
Resident #5, age [AGE], was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke) and dementia.
The 10/26/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. She was dependent with toileting, required substantial/maximal assistance with transfers, partial/moderate assistance with personal hygiene and bed mobility and set up assistance with eating.
The assessment indicated Resident #5 had functional limitation of range of motion (ROM) on one side for upper and lower extremities.
B. Observations
On 12/16/24 at 10:00 a.m. Resident #5 was observed lying on her back in bed leaning to her right side.
On 12/16/24 at 1:10 p.m. Resident #5 was observed lying on her back in bed leaning to her right side.
On 12/16/24 at 3:00 p.m. Resident #5 was observed lying on her back in bed leaning to her right side.
On 12/17/24 at 9:58 a.m. Resident #5 was observed being wheeled to her room with one staff member. The resident and the one staff member entered the room and closed the door.
On 12/17/24 at 10:10 a.m. Resident #5's door opened and the one staff member left the room. Resident #5 was sitting in her recliner.
-A second staff member did not enter Resident #5's room to assist with the transfer (see PT discharge summary below).
On 12/17/24 at 10:40 a.m. Resident #5 was sitting in her recliner and leaning over the right arm of the recliner.
C. Record review
The activities of daily living (ADL) care plan, initiated 4/12/23 and revised 7/3/24, documented that Resident #5 was at risk for self care performance related to cognitive impairment, stroke and functional limitation in ROM related to hemiplegia (weakness on one side of the body). Interventions included assisting with ADLs, encouraging participation in ADLs, encouraging the resident to use her call light for assistance, monitoring for pain during ADLs, physical therapy (PT), occupational therapy (OT) and speech therapy screen and evaluation as necessary and one person assistance for toileting and transfers.
-The ADL care plan failed to reveal Resident #5 required a maximum assistance of two people or a hoyer (mechanical) lift with transfers (see PT discharge summary below).
-Additionally, the ADL care plan failed to include providing gentle ROM with ADLs and positioning interventions (see OT discharge summary below).
The 8/29/24 OT evaluation and plan of treatment note documented Resident #5 needed skilled interventions to address positioning issues and provide education to staff to maintain gains achieved during therapy. It also documented facilitation of proper seating in a recliner or bed to reduce pressure and maintain skin integrity.
The 9/21/24 OT discharge summary note recommendations documented nursing staff was provided education on providing gentle ROM with hygiene activities and ADLs and positioning in wheelchair.
The 10/17/24 PT evaluation and plan of treatment note documented Resident #5 had left sided hemiplegia with impaired posture, mobility and transfer with decreased safety during transfers with need for staff training and education for safe transfers with dependent assistance to reduce fall and injury risk.
The 11/13/24 PT discharge summary note recommendations documented two persons maximum assistance or a hoyer lift were required for Resident #5's transfers.
-A comprehensive review of Resident #5's electronic medical record (EMR) failed to reveal documentation of nursing staff offering or providing ROM during ADLs or implementing personalized positioning interventions.
II. Staff interviews
The physical therapy assistant (PTA) was interviewed on 12/18/24 at 9:41 a.m. The PTA said Resident #5 was unable to ambulate but was able to use her right side to help pivot during transfers. She said she had been seen by PT and OT for issues with positioning, transfers and bed mobility. She said the facility did not have a physical therapist on site. She said a PT came once a month or held telehealth visits. She said Resident #5 still required assistance with positioning, balance and transfers and still required maximum assistance or a hoyer lift for transfers. She said Resident #5 was discharged from PT in November 2024 and the recommendations for Resident #5's transfers and positioning were reviewed with certified nurse aides (CNA) at that time. She said the discharge recommendations were for the assistance of two maximum people or a hoyer lift for transfers and positioning to keep Resident #5 from leaning to her right side. She said Resident #5 did not tolerate the ROM stretches.
The PTA said she did not have formal documentation on the education provided to the CNAs regarding Resident #5's transfers and positioning recommendations. She said since the education was provided, there had been a change of staff. She said she did not have access to the nursing documentation and did not know how the education and communication provided by PT and OT was communicated between members of the nursing staff. The PTA said the interventions should be included in the nursing care plan.
CNA #3 was interviewed on 12/19/24 at 9:00 a.m. CNA #3 said Resident #5 was able to bear weight on her right leg with transfers. He said it was best to transfer the resident with a two person assist and a gait belt. He said Resident #5 was sometimes transferred with only one person assistance. He said he was unsure why she had been transferred with only one person. He said CNAs could get information from care plans and change of shift reports from other CNAs and nurses regarding residents' transfer and positioning status. He said he was not aware of any communication from PT or OT to nursing staff regarding transfers or positioning for Resident #5. CNA #3 said the nursing staff just knew the residents well enough to know what kind of assistance they needed.
-However, observations revealed Resident #5 was transferred from her wheelchair to her recliner with the assistance of only one staff member (see observations above).
The director of nursing (DON) and the NHA were interviewed together on 12/19/24 at 9:30 a.m. The NHA said the facility was working on getting an in-house physical therapist. She said the facility did not have a process in place currently when a resident was discharged from PT and OT on how recommendations were communicated and documented to and by nursing staff. She said it was important to have a process in place to ensure continuity of care between therapy and nursing staff so the residents could continue to maintain their optimal level of functioning.
The NHA said Resident #5 had skin tears that had happened during transfers. She said she was not aware the resident should be transferred with the assistance of two people or a hoyer lift.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure one (#4) of three residents out of 41 sample r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure one (#4) of three residents out of 41 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan.
Specifically, the facility failed to follow the physician's orders for Resident #4's pain medications and dressing changes.
I. Facility policy and procedure
The Administering Medications policy, revised April 2019, was provided by the nursing home administrator (NHA) on 12/19/124 at 9:03 a.m. It read in pertinent part,
Medications are administered in a safe and timely manner, and as prescribed.
If a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the medication administration record space provided for the drug and dose.
II. Resident #4
A. Resident status
Resident #4, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician order (CPO) diagnoses included heart failure, osteoarthritis and osteoporosis.
The 8/19/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15.
The 11/17/24 MDS assessment revealed she was on a pain medication regimen and received non-medication interventions for pain. She had pain in the past five days. She received skin treatments that included application of ointments and medications.
The assessment revealed the resident did not reject care.
B. Resident interview and observations
Resident #4 was interviewed on 12/16/24 at 2:02 p.m. Resident #4 was in a wheelchair next to an over the bed table. She had ted hose on both lower extremities. She said she had pain in her hips, her knees and her shins. Resident #4 said she had bandages on her lower extremities because she went to the hospital four days ago because her legs were leaking. She was not sure what caused the leaking but she thought it was because she had heart disease.
C. Record review
A review of the October 2024 CPO revealed the following physician's orders for pain management:
-Lidocaine external patch four percent, apply to the left hip topically in the morning for pain, ordered 3/4/24.
-Lidocaine external patch four percent, apply to the right buttock topically in the morning for pain, ordered 3/4/24.
A review of the October 2024 medication administration record (MAR) revealed the lidocaine external patch four percent was not administered to the left hip and to the right buttock on 10/2/24, 10/3/24, 10/4/24, 10/5/24, 10/6/24, 10/7/24, 10/8/24, 10/9/24, 10/10/24, 10/11/24, 10/12/24, 10/13/24, 10/14/24, 10/15/24, 10/16/24, 10/17/24, 10/18/24 and 10/19/24.
The October 2024 progress notes revealed the lidocaine external patch was not administered on to the left hip and to the right buttock from 10/2/24 to 10/19/24 because the medication was not available.
-However, a review of the resident's electronic medical record (EMR) revealed there was no documentation the provider was notified the medication was not available and there was no documentation why the medication was not available.
A review of the December 2024 CPO revealed the following physician's orders for wound care:
-Daily dressing change to the right lower extremity for weeping edema, cleanse area, apply telfa (wound dressing), ABD pad and ace wrap, check the area every two hours, order until symptoms resolve, one time a day for weeping edema to the right lower extremity, ordered 12/6/24 and discontinued 12/12/24.
A review of the December 2024 MAR revealed the daily dressing change to the resident's right lower extremity was not completed on 12/6/24, 12/9/24 and 12/11/24.
The December 2024 progress notes revealed the dressing change was not completed on 12/6/24, 12/9/24 and 12/11/24 because the site was healed.
-However, a review of the resident's electronic medical record revealed there was no documentation the provider was notified the site was healed.
D. Staff interviews
Certified nurse aide with medication authority (CNA-Med) #1 was interviewed on 12/18/24 at 9:23 a.m. CNA-Med #1 said she knew a resident was in pain based on facial expressions and if the resident told her verbally. She said she told a nurse if she knew the resident was in pain. CNA-Med #1 said Resident #4 had pain mostly in her back and in her right knee. CNA-Med #1 said Resident #4 recently had pain more frequently. She said Resident #4 had the pain because she had sciatica and arthritis. CNA-Med #1 said pain medication and lidocaine patches helped with her pain.
CNA-Med #1 said if a medication was not available in the medication cart, she would see if there was any available in the central supply closet. She said if there was not any available, she would notify the nurse. CNA-Med #1 did not know why Resident #4 did not have lidocaine patches in October 2024 and did not know why the dressing changes were not done.
The director of nursing (DON) was interviewed on 12/18/24 at 4:01 p.m. The DON said if a wound was healed, the nurse should look at the order The DON said the nurse should look at the order because sometimes the provider said to discontinue the treatment when the wound was healed. The DON said if the order did not have orders to discontinue when healed, the nurse should contact the provider and monitor the site for symptoms. The DON did not know why Resident #4 dressing administration record showed it was healed on some days and why it was completed on the other days. The DON said the wound was healed.
The DON said if a medication was not available, the nurse checked the central supply closet. She said if there was no medication available in the central supply closet, the nurse should reorder and contact the provider. The DON said she was not in her current position when the lidocaine was not administered for Resident #4.
The DON and the NHA were interviewed together on 12/19/24 at 9:34 a.m. The DON said she reviewed the dressing orders for Resident #4. The DON said the orders should have been more clear. The DON and the NHA said there should have been one order to administer dressing changes and one order to monitor the site.
The NHA said she did not know why the lidocaine patches were not administered in October 2024 for 18 days. She said it could have been an insurance issue or it could have been an availability issue. She said the nurse should have contacted the provider if the medication was not administered. The NHA said the nurse should have had a progress note on why the medication was not administered and the provider was notified. The NHA said the provider needed to be contacted to see if it was ok to hold the medication, change the order or some other direction. The NHA said they had access to go to a local pharmacy and to a retail pharmacy. The NHA said the facility should not have waited and found a way for the resident to have her medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outc...
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Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two of five certified nurse aides (CNA) reviewed.
Specifically, the facility did not complete a performance review and provide regular in-service education for CNA #2 and CNA #4.
Findings include:
I. Record review
CNA #2 was hired on 8/1/19. A request for a performance review was made on 12/17/24.
-The facility was unable to provide documentation indicating a performance review for CNA #2 was completed in the past 12 months.
CNA #4 was hired on 5/1/23. A request for a performance review was made on 12/17/24.
-The facility was unable to provide documentation indicating a performance review for CNA #4 was completed in the past 12 months.
II. Staff interviews
The director of nursing (DON) and the nursing home administrator (NHA) were interviewed on 12/18/24 at 12:25 p.m. The DON said she started work as a floor nurse at the facility in September 2024 and became the DON in October 2024. The DON said she was responsible for completing performance reviews and in-service education for CNAs.
The NHA said performance reviews were completed based on the CNAs start date. The NHA said a performance review was not completed for CNA #2 and CNA #4.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent.
Specifically, the facility's medication error rate was 5...
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Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent.
Specifically, the facility's medication error rate was 5.88% with two errors out of 34 opportunities for error.
Findings include:
I. Professional reference
According to the the Lispro (Humalog) insulin Kwik Pen manufacturer instruction, last updated July 2023, retrieved on 12/30/24 from https://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf,
Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen is working correctly. If you do not prime before each injection you may get too much or too little insulin.
To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle.
II. Facility policy and procedure
The Administering Medication policy and procedure, reviewed April 2019, was provided by the nursing home administrator (NHA) on 12/19/24 at 9:03 a.m. It read in pertinent part,
Medications are administered in accordance with prescriber orders, including any required time frame.
The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
III. Observations
On 12/18/24 at 11:20 a.m. registered nurse (RN) #1 checked Resident #13's insulin order for Lispro insulin five units to be administered before lunch per sliding scale for a blood glucose level of 262.
RN #1 placed a new disposable needle onto the insulin pen and dialed one unit of insulin into the insulin pen. She pushed the one unit of insulin through the pen.
RN #1 then dialed five units of insulin into the pen and administered the insulin into the back of Resident#13's right arm. After administering the insulin, RN #1 removed the needle from the insulin pen and placed it in the sharps container.
-RN #1 failed to prime the insulin pen appropriately with two units of insulin prior to administering Resident #13's five units of insulin (see professional reference above).
On 12/19/24 at 8:00 a.m. certified nurse aide with medication authority (CNA-Med) #2 checked Resident #44's order for aripiprazole five milligrams (mg) to be administered every morning. She obtained Resident #44's aripiprazole medication card which contained unscored ten mg tablets. She went to the medication room and was unable to find a card for Resident #44's aripiprazole five mg tablets. She notified the nurse at the desk to order the aripiprazole five mg tablets for Resident #44. She also notified the nurse at the desk to notify the provider the medication was held because the correct dosage was unavailable for administration.
-Resident #44 did not receive the medication on 12/19/24 due to the correct dose of the medication being unavailable.
IV. Staff interviews
RN #1 was interviewed on 12/18/24 at 11:30 a.m. She said her practice for priming any insulin pen was to prime it with one unit of insulin because this was what she was taught. She said she did not know the manufacturer's recommendations for priming the Lispro insulin pen. She said it was important to prime the insulin pen correctly in order to administer the correct dose of insulin.
The NHA was interviewed on 12/18/24 at 11:35 a.m. She said she was unsure of how much insulin was needed to prime insulin pens. She said she would get the correct priming information from the pharmacy regarding the pens to ensure residents received the correct dose of insulin.
The NHA was interviewed a second time on 12/18/24 at 12:30 p.m. The NHA said the correct dose of insulin to prime the Lispro (Humalog) insulin pen was two units. She said the facility was providing education to all nurses on the correct way to prime insulin pens and to follow manufacturer's recommendations on priming insulin pens.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the residents were free from significant medi...
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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 the residents were free from significant medication errors for one (#13) of seven residents reviewed for medication errors out of 41 sample residents.
Specifically, the facility failed to ensure that Resident #13 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration.
Findings include:
I. Professional reference
According to the the Lispro (Humalog) insulin Kwik Pen manufacturer instruction, updated July 2023, retrieved on 12/20/24 from https://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf,
Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen is working correctly. If you do not prime before each injection you may get too much or too little insulin.
To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle.
II. Resident #13
A. Resident status
Resident #13, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus (DM) and hypertension.
The 9/9/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required supervision with eating, toileting, personal hygiene, transfers and was independent with bed mobility.
B. Observations
On 12/18/24 at 11:20 a.m. registered nurse (RN) #1 checked Resident #13's insulin order for Lispro insulin five units to be administered before lunch per sliding scale for a blood glucose level of 262.
RN #1 placed a new disposable needle onto the insulin pen and dialed one unit of insulin into the insulin pen. She pushed the one unit of insulin through the pen.
RN #1 then dialed five units of insulin into the pen and administered the insulin into the back of Resident#13's right arm. After administering the insulin, RN #1 removed the needle from the insulin pen and placed it in the sharps container.
-RN #1 failed to prime the insulin pen appropriately with two units of insulin prior to administering Resident #13's five units of insulin (see professional reference above).
C. Record review
Review of Resident #13's December 2024 CPO revealed a physician's order for Humalog (Lispro) insulin 100 units/milliliter (ml) to inject five units per sliding scale for a blood glucose of 251-999 subcutaneously before meals for diabetes mellitus, ordered 9/3/24.
III. Staff interviews
RN #1 was interviewed on 12/18/24 at 11:30 a.m. She said her practice for priming any insulin pen was to prime it with one unit of insulin because this was what she was taught. She said she did not know the manufacturer's recommendations for priming the Lispro insulin pen. She said it was important to prime the insulin pen correctly in order to administer the correct dose of insulin.
The nursing home administrator (NHA) was interviewed on 12/18/24 at 11:35 a.m. She said she was unsure of how much insulin was needed to prime insulin pens. She said she would get the correct priming information from the pharmacy regarding the pens to ensure residents received the correct dose of insulin.
The NHA was interviewed a second time on 12/18/24 at 12:30 p.m. The NHA said the correct dose of insulin to prime the Lispro (Humalog) insulin pen was two units. She said the facility was providing education to all nurses on the correct way to prime insulin pens and to follow manufacturer's recommendations on priming insulin pens.
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 F0806
(Tag F0806)
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 meals were served according to the resident's...
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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 meals were served according to the resident's preferences for one (#12) of two residents out of 41 sample residents.
Specifically, the facility failed to offer food choices according to Resident #12's preferences.
Findings include:
I. Facility policy and procedure
The Food Preparation and Serving policy, undated, was provided by the nursing home administrator (NHA) on 12/19/124 at 9:03 a.m. It read in pertinent part, Special care is given when purchasing food to select fresh food when possible.
Between meals and bedtime snacks are offered. These snacks are of a nutritious quality.
II. Resident #12
A. Resident status
Resident #12, age less than 65, was admitted on [DATE]. According to the December computerized physician orders (CPO) diagnoses included type 2 diabetes mellitus, cerebral infarction (stroke), hemiplegia (paralysis on one side) and hemiparesis (weakness or inability to move one side of the body), chronic obstructive pulmonary disease (COPD), epilepsy (seizure disorder), depressive episodes and anxiety.
The 9/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15.
The 7/19/24 MDS assessment revealed it was very important to have snacks available between meals. It revealed the resident had an obvious or likely cavity or broken natural teeth.
B. Resident interview and observation
Resident #12 was interviewed on 12/16/24 at 2:52 p.m. He said he liked grapes as a snack and the facility had been out of grapes for a long time. He said it was frustrating the dietary department was not trying to find an alternative. He said he did not like bananas and apples were too hard to eat because of his teeth.
Resident #12 said if he was the dietary manager (DM) and he was out of something, he would find an alternative or go to the grocery store right that was next door to see if they had grapes.
During the interview, dietary aide (DA) #1 walked into Resident #12's room. She offered the resident a chocolate cookie and a chex mix snack. Resident #12 asked for grapes and DA #1 said she did not have grapes.
C. Record review
The nutrition care plan, revised 7/30/24, revealed the resident was at risk for altered nutritional status related to obesity, gastroesophageal reflux disease (GERD), diabetes and edema. Interventions included keeping the resident's food preferences up to date and providing meals, snacks and fluids.
The 8/19/24 nutritional risk assessment revealed the residents liked sweets, sweet tea, chips, fruit loops, peanut butter, grapes, corn, jello and pork.
D. Observations
On 12/18/24 at 11:10 a.m. during a kitchen tour, grapes were not observed in the kitchen.
E. Staff interviews
On 12/17/24 at 2:54 p.m., DA #1 was in the F hallway with a snack cart. She said she had chips, [NAME] butter cookies and chocolate cookies to offer residents as a snack. She said she should offered the residents chips, [NAME] butter cookies, cookies, yogurt, pudding and fruit. She said she had yogurt in the kitchen. DA #1 said she did not have fresh fruit to offer and she was not sure if pudding was currently available. DA #1 was familiar with Resident #12 and she said he always asked for grapes.
The DM was interviewed on 12/18/24 at 2:53 p.m. She said she started as the DM on 12/16/24. She said she had worked at the facility since July 2024. She said she was responsible for obtaining the resident's food preferences. She said she has not been trained on how and when to obtain the resident's preference.
The DM said snacks were offered to all residents. The DM said residents prescribed a pureed diet were offered pudding, apple sauce and pureed cake. She said the three types of pudding were vanilla, butterscotch and lemon. She said residents loved butterscotch and she had been out of butterscotch pudding for the past three days. She said residents prescribed a regular diet were offered chips, cookies, chex mix, goldfish, sandwiches, fruit cups, yogurt and [NAME] butter cookies. She said residents prescribed a diabetic diet were offered chips, goldfish, sugar free applesauce, broccoli and ranch, and celery with peanut butter.
The DM said the residents knew what snacks were offered because the DAs had the cart with them when they went room to room. She said the list of snacks was not posted in the resident's room but she planned to have the list available so the residents knew what snacks were available.
The DM said the previous DM did not order enough snacks for the residents. The DM said the facility did not have enough snacks for the residents since she started\. She said there were times when the facility was out of chips for a week or out of peanut butter for three days. She said the residents loved peanut butter and jelly sandwiches. The DM said there was no reason to not go to the store. She said she went to the store today to get an item for lunch.
The DM said Resident #12 liked nacho tortilla chips, chex mix, pudding, gummy bears and grapes. The DM said he often refused dinner and wanted grapes. The DM said he liked vanilla and chocolate pudding. The DM said the facility has not had grapes for a while. She said the previous DM did not order grapes. The DM said she had not been trained on placing the food order, so the facility was currently receiving orders based on the previous DM's order list. She said that list did not include grapes.
The DM said it was important to have snacks residents liked because the facility was their home. She said if the dietary staff knew a resident had a bad day the staff could offer food the resident liked. She said it was also important to offer the residents food they liked because the residents would be upset if they had to tell the dietary staff what they liked.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the develo...
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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 prevent the development and transmission of disease and infection in one of four units.
Specifically, the facility failed to ensure glucometers were cleaned in a sanitary manner.
I. Professional reference
The Centers for Disease Control and Prevention (CDC) Considerations for Blood Glucose Monitoring and Insulin Administration (8/7/24), was retrieved on 12/27/24 from https://www.cdc.gov/injection-safety/hcp/infection-control/index.html#:~:text=Unsafe%20practices%20during%20assisted%20monitoring,for%20more%20than%20one%20person. It read in pertinent part,
Unsafe practices during assisted monitoring of blood glucose and insulin administration contribute to the spread of hepatitis B virus, hepatitis C virus, human immunodeficiency virus (HIV) and other infections. Unsafe practices include: using fingerstick devices for more than one person, using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses.
II. Facility policy and procedure
The Capillary Blood Sampling policy and procedure, reviewed September 2014, was provided by the nursing home administrator (NHA) on 12/19/24 at 9:03 a.m. It read in pertinent part,
Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use.
III. Manufacturer's recommendations
The Arkray Assure Platinum Blood Glucose Meter manufacturer cleaning and disinfecting guidelines, 2024, were retrieved on 12/27/24 at 1:17 p.m. from https://arkrayusa.com/diabetes-management/professional-healthcare-products/assure/assure-platinum. It read in pertinent part,
The Assure Platinum blood glucose meter may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedure are followed.
The meter should be cleaned and disinfected after use on each patient.
Disinfecting the meter can be accomplished with an environmental protection agency (EPA) registered disinfectant detergent or germicide that is approved for healthcare settings or a solution of 1:10 concentration of sodium hypochlorite (bleach).
Each time the cleaning and disinfecting procedure is performed two wipes are needed. One wipe to clean the meter and a second wipe to disinfect the meter.
The Super Sani Cloth Germicidal Disposable Wipe manufacturer guidelines, 2024, were retrieved on 12/27/24 from https://pdihc.com/products/environment-of-care/super-sani-cloth-germicidal-disposable-wipe. It read in pertinent part,
Bactericidal, Tuberculocidal, Virucidal and Fungicidal. Overall contact time is two minutes.
IV. Observations
On 12/18/24 at 11:15 a.m. registered nurse (RN) #1 took an unlabeled glucometer out of the medication cart. She went to Resident #11's room and used the glucometer to obtain the resident's blood glucose level. She returned to the medication cart, wiped off the blood glucometer with one Super Sani Cloth germicidal wipe and let the glucometer dry.
-RN #1 did not use two wipes to clean and disinfect the meter (see manufacturer's recommendations above).
-RN #1 did not leave the glucometer wet for the two minute disinfection time (see manufacturer's recommendations above).
On 12/18/24 at 11:25 a.m. RN #1 took the same unlabeled glucometer from the medication cart and used it to obtain a blood glucose level from Resident #13. She then returned to the medication cart with the blood glucometer and wiped the glucometer with one Super Sani Cloth germicidal wipe and let the glucometer dry.
-RN #1 did not use two wipes to clean and disinfect the meter (see manufacturer's recommendations above).
-RN #1 did not leave the glucometer wet for the two minute disinfection time (see manufacturer's recommendations above).
V. Record review
Review of the 10 residents in the facility who received blood glucose checks with a glucometer, completed on 12/18/24, revealed there were no residents with a diagnosis for a transmittable blood-borne disease.
VI. Staff interviews
RN #1 was interviewed on 12/18/24 at 11:30 a.m. RN #1 said that her practice after wiping the glucometer with a Super Sani Cloth germicidal wipe was to immediately let the glucometer dry. She said she did not know the disinfection time of the Super Sani Cloth wipes or how long the glucometers needed to stay wet after they were cleaned and disinfected. She said it was important to clean glucometers correctly to prevent the spread of blood-borne pathogens.
The NHA was interviewed on 12/18/24 at 11:35 a.m. The NHA said nursing staff should be cleaning and disinfecting the glucometers according to the manufacturer's recommendations to ensure the glucometer was appropriately disinfected for blood-borne pathogens. She said the glucometer manufacturer's recommendations on how to clean the blood glucometers would be reviewed with the nursing staff. She said the facility would ensure residents had their own designated glucometers so glucometers were not shared between residents.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to promote and maintain the resident's dignity for four...
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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 promote and maintain the resident's dignity for four (#3, #39, #49 and #51) of five residents reviewed for dignity and respect out of 41 sample residents.
Specifically, the facility failed to ensure Resident #3, Resident #39, Resident #51 and Resident #49's call lights were in reach.
Findings include:
I. Facility policy and procedure
The Call System policy, dated September 2022, was provided by the nursing home administrator (NHA) on 12/19/24 at 2:07 p.m. It read in pertinent part, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station.
Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.
If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.
Answering the Call Light procedure, revised September 2022, was received by the NHA on 12/19/24 at 9:03 a.m. It read in pertinent part, The purpose of this procedure is to ensure timely responses to the resident's requests and needs.
Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident.
Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.
II. Resident #3
A. Resident status
Resident #3, age greater than 65, was initially admitted on [DATE] and readmitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included chronic respiratory failure (a long term condition that prevents the body from exchanging oxygen and carbon dioxide properly) and dementia.
The 12/6/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. She was dependent on staff for assistance with toileting hygiene, lower body dressing and putting on/taking off footwear.
The MDS assessment documented the resident had an impairment on one side of her upper extremity. She had impairment on both sides for lower extremities.
B. Observation
On 12/17/24 at 1:17 pm Resident #3 called out and asked could you please hand me my call light. Resident #3 was seated in her bedside chair and her call light was on the bed and out of reach.
C. Record review
The activity of daily living (ADL) care plan, revised 6/30/24, documented Resident #3 had an ADL self-care performance deficit related to cognitive impairments, history of falls and impaired mobility. Interventions included: encouraging the resident to use her call light when assistance was needed and placing call light within reach.
The care plan for falls, revised 9/11/24, documented Resident #3 was at risk for falls related to a history of falls. Interventions included: educating the resident and the family to call for assistance before transferring, ensuring the call light was within reach, educating the resident to use call light and ensuring needed items within reach.
III. Resident #39
A. Resident status
Resident #39, age greater than 65, was initially admitted on [DATE] and readmitted on [DATE]. According to the December 2024 CPO, diagnoses included chronic kidney disease stage four, Alzheimer's disease and dementia.
The 10/28/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of six out of 15. She required supervision or touching assistance with eating, oral hygiene, toileting hygiene, upper body dressing, putting on/taking off footwear and personal hygiene.
B. Observations and resident interview
On 12/16/24 at 3:24 p.m. Resident #39's call light was located on the floor between her recliner chair and bed. The call light was out of reach for Resident #39.
On 12/18/24 at 9:38 a.m. Resident #39's call light was located on the floor between her recliner chair and bed.
On 12/18/24 at 4:28 p.m. Resident #39's call light was on the floor between her recliner chair and bed.
On 12/19/24 at 9:50 a.m. Resident #39 said she did not know where her call light was at. She said if she needed any help she would get up and ask for help.
C. Record review
The care plan for ADL, revised 7/18/24, documented Resident #39 had ADL self-care performance deficit related to dementia and hypoxia. Interventions included: encouraging the resident to use her call light when assistance was needed and placing assistive devices within reach.
IV. Resident #49
A. Resident status
Resident #49, age [AGE], was initially admitted on [DATE] and readmitted on [DATE]. According to the December 2024 CPO, diagnoses included ataxic gait (a type of walking characterized by an inability to coordinate movements, resulting in an awkward, unsteady and wide based gait), traumatic brain injury and depression.
The 11/20/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was dependent on staff assistance with eating, oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene.
The MDS assessment documented the resident had impairment on both sides for upper and lower extremity.
B. Observations and resident interview
Resident #49 was interviewed on 12/16/24 at 4:28 p.m. Resident #49's call light was placed in his dresser drawer next to his bed. Resident #49 said he was not able to reach his call light. He said half of the time he did not know where his call light was at. He said he was not able to reach his call light in his drawer.
Resident #49 was interviewed on 12/18/24 at 4:25 p.m. Resident #49's call light was clipped to the side of his bed. Resident #49 said he did not know where his call light was and said he could not reach the side of his bed.
Resident #49 was interviewed on 12/19/24 at 9:33 a.m. Resident #49 said when he was not able to reach his call light made him feel helpless. He said when he was not able to reach his call light that he would call out for help. He said he has had to yell for help once to twice a day. He said he did not like to yell for help and said he wanted his call light to be within reach.
C. Record review
The ADL care plan, revised 9/4/24, documented Resident #49 had ADL self-care performance deficit. Interventions included: encouraging the resident to use call light when assistance was needed, placing assistive devices within reach and placing call light within reach.
V. Resident #51
A. Resident status
Resident #51, age greater than 65, was initially admitted on [DATE] and readmitted on [DATE]. According to the December 2024 CPO, diagnoses included respiratory failure, depression and dementia.
The 12/13/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of six out of 15. She required substantial/maximal assistance with toileting hygiene, showering/bathing self, lower body dressing and putting on/taking off footwear.
B. Observation
On 12/16/24 at 4:09 p.m. Resident #51's call light was on the floor by the foot of the resident's bed. Resident #51 was sitting in her wheelchair.
C. Record review
The ADL care plan, revised 7/1/24, documented Resident #51 had ADL self-care performance deficit related to weakness from prolonged hospital stay due to COVID-19, pneumonia. Interventions included: allowing time for the resident to express feelings of frustration regarding the need for assistance in ADL tasks, encouraging the resident to use call light when assistance was needed, placing assistive devices within reach and placing call light within reach.
D. Staff interviews
Certified nurse aide (CNA) #1 was interviewed on 12/19/24 at 10:02 a.m. CNA #1 said the call lights should be placed within reach for all residents. CNA #1 said the call lights should be clipped onto the residents bed or sheet, within the residents reach.
CNA #1 said all staff were responsible for making sure the call lights were within reach of the residents. She said every time a staff member went in to check on a resident, the staff member should ensure the call light was within reach. She said the call lights should never be out of reach for residents.
CNA #1 said the call lights should not be on the floor. CNA #1 said if residents could not hold the call light that she would use clips to clip the call light close to them. She said if she saw the call light on the floor she would pick it up and place the call light within reach.
Licensed practical nurse (LPN) #1 was interviewed on 12/19/24 at 10:12 a.m. LPN #1 said the call lights should be placed near the residents so they could grab it. She said every one that came into contact with residents should make sure call lights were within reach.
LPN #1 said the call lights should not be on the floor because they could be contaminated. LPN #1 said if the call lights were not within reach, the resident could not call for help. She said the call lights should not be out of reach for residents with limited range of motion because they could not call for help if they need anything.
The director of nursing (DON) and the NHA were interviewed together on 12/19/24 at 10:19 a.m. The DON said the call lights should always be placed within the residents reach. The DON said the residents used their call lights to call for assistance.
The DON and the NHA said all of the staff were responsible for ensuring the call lights were within reach of the residents. The DON said the call lights should never be on the floor. She said if the call light was not within reach that it should be addressed right away and placed within reach. She said call lights should always be in reach.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0659
(Tag F0659)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to ensure residents received care from qualified employees for 11 (#15, #5, #46, #49, #34, #6, #19, #262, #45, #47 and #24) of 11 residents o...
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Based on record review and interviews, the facility failed to ensure residents received care from qualified employees for 11 (#15, #5, #46, #49, #34, #6, #19, #262, #45, #47 and #24) of 11 residents out of 41 sample residents.
Specifically, the facility failed to ensure qualified and credentialed staff received, entered, confirmed and revised verbal and written physician's orders for Residents #15, #5, #46, #49, #34, #6, #19, #262, #45, #47 and #24.
Findings include:
I. Record review
A. Resident #15
Review of Resident #15's December 2024 computerized physician orders (CPO) revealed the following physician's orders:
Tylenol, give as needed every eight hours, not to exceed three grams of tylenol in 24 hours, ordered 2/1/23.
-The physician's order was created and confirmed by the medical records assistant (MRA).
Shortness of breath while lying flat, ordered 10/23/24.
-The physician's order was created and confirmed by the MRA.
B. Resident #5
Review of Resident #5's December 2024 CPO revealed the following physician's order:
Amlodipine besylate tablet 10 milligrams (mg), give one tablet by mouth one time a day related to heart and kidney disease without heart failure, with stage one through stage four chronic kidney disease or unspecified chronic kidney disease, ordered 2/1/23.
-The physician's order was created, confirmed and revised by the MRA.
C. Resident #46
Review of Resident #46's December 2024 CPO revealed the following physician's orders:
Diet type, regular with fortified food for risk for malnutrition, ordered 9/19/24.
-The physician's order was created by the MRA.
D. Resident #49
Review of Resident #49's December 2024 CPO revealed the following physician's order:
Speech therapy evaluate and treat as indicated, ordered 10/18/24.
-The physician's order was created and confirmed by the MRA.
E. Resident #4
Review of Resident #34's December 2024 CPO revealed the following physician's orders:
Referral to dermatology for hair loss and itchy/painful scar, ordered 3/28/24.
-The physician's order was created and confirmed by the MRA.
Diagnosis chronic sinusitis, unspecified, ordered 3/5/24.
The physician's order was created and confirmed by the MRA.
Potassium, total dose = 20 milliequivalents (mEq), ordered 1/5/24).
-The physician's order was created and confirmed by the MRA.
F. Resident #6
Review of Resident #6's December 2024 CPO revealed the following physician's order:
Nebulizer use, as needed every four hours, ordered 3/6/24.
-The physician's order was created and confirmed by the MRA.
G. Resident #19
Review of Resident #19's December 2024 CPO revealed the following physician's orders:
May apply barrier cream after incontinence episode, ordered 9/13/24.
-The physician's order was created and confirmed by the MRA.
Drain catheter every four hours or as needed, record characteristics and amount, ordered 6/24/24.
-The physician's order was created and confirmed by the MRA.
H. Resident #262
Review of Resident #262's December 2024 CPO revealed the following physician's orders:
Shortness of breath while laying flat, ordered 10/23/24.
-The physician's order was created and confirmed by the MRA.
May apply barrier cream after incontinence episode, ordered 9/13/23.
-The physician's order was created and confirmed by the MRA.
Diagnosis for foley catheter: chronic kidney disease, stage 3, retention of urine, ordered 10/13/24.
-The physician's order was created, confirmed and revised by the MRA.
May discontinue as needed medications not used for 60 days with the exception of milk of magnesia and Tylenol, ordered 9/13/24.
The physician's order was created and confirmed by the MRA.
Observe closely for side effects of diuretic medication including decreased oral intake, acute confusion, agitation, delusions, aggression, tiredness, decreased sweating, rapid heart rate, low blood pressure, generalized weakness, and sunken eyes, ordered 9/13/24.
-The physician's order was created and confirmed by the MRA.
I. Resident #45
Review of Resident #45's December 2024 CPO revealed the following physician's order:
Nebulizer: assess prior to administering nebulizer treatment document lung sounds as 1=clear 2=rales 3=congested 4=crackles 5=rhonchi 6=rubs 7=wheezing 8=diminished, ordered 1/18/24.
-The physician's order was created and confirmed by the MRA.
J. Resident #47
Review of Resident #47's December 2024 CPO revealed the following physician's order:
May crush medication unless contraindicated, ordered 11/15/24.
-The physician's order was created and confirmed by the MRA.
K. Resident #24
Review of Resident #24's December 2024 CPO revealed the following physician's order:
Hemodialysis every Tuesday, Thursday, and Saturday, ordered 12/10/24.
-The physician's order was created and confirmed by the MRA.
II. Staff interviews
The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 12/18/24 at 11:40 a.m. The DON said the MRA was also a certified nursing assistant (CNA) and had been permitted to enter verbal physician orders when the orders were received by electronic communication from the physician.
The NHA said that CNAs were not permitted to create, confirm or revise physician orders because it was not in the scope of practice for a CNA.
The DON and the NHA said they were unaware the MRA had been confirming and revising residents' physician's orders. The DON and the NHA said they would educate the MRA that she was not permitted to create, confirm or revise physician's orders.
III. Facility follow-up
On 12/18/24 at 4:12 p.m., the NHA provided documentation that physician's order entry education was completed with the medical records staff and nursing administration. The education clarified that only nurses could enter or confirm physician's orders for residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, record review and interviews, the facility failed to prepare, distribute and serve food in a sanitary manner in the main kitchen.
Specifically, the facility failed to ensure han...
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Based on observations, record review and interviews, the facility failed to prepare, distribute and serve food in a sanitary manner in the main kitchen.
Specifically, the facility failed to ensure hand hygiene was conducted appropriately in the main kitchen.
Findings include:
I. Professional reference
The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 12/24/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.
If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.
II. Facility policy and procedure
The Handwashing and Hand Hygiene policy and procedure, revised August 2019, was provided by the nursing home administrator (NHA) on 12/19/24 at 2:07 p.m. It read in pertinent part, All personnel shall be trained and regularly in-services on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.
All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.
The use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
When applying and removing gloves, perform hand hygiene before applying non-sterile gloves.
II. Observation
During a continuous observation during the lunch meal on 12/18/24, beginning at 11:00 a.m. and ending at 2:00 p.m., the following was observed:
Cook (CK) #1 reached into the bucket of sanitizer and got a towel. He began sanitizing his work area. He put the towel back into the sanitizer bucket and picked up some dirty dishes and took them to the dish area. He took his gloves off and put a new pair of gloves on without washing his hands.
CK #1 had gloves on, grabbed the hot pads and pulled the meatloaf out of the oven and sat it on the counter.
Without removing his gloves, he got a knife from the drawer and began slicing the meatloaf. When he was done slicing up the meatloaf he took the pan and placed it on the steam table. He took his gloves off and put new gloves on without washing his hands.
With the same gloves hands CK #1 went into the back room and grabbed a bag of instant mashed potatoes. He grabbed the scissors and opened the bag and poured the bag of instant mashed potatoes into the pan. He grabbed a picture of water and filled it up with hot water. He poured the hot water into the pan of instant mashed potatoes and began mixing the mashed potatoes. When he was done mixing the potatoes he placed the pan on the steam table. He then took his gloves off and then put new gloves on without washing his hands.
With his gloved hands CK #1 grabbed a spatula from the drawer and placed four pieces of meatloaf in the blender. He got a measuring cup, went to the sink and filled it with water. He then poured the water into the blender. When he was done pureeing the meatloaf he took it over to the steam table. He grabbed a small pan and scooped the pureed meatloaf into the pan. When he was done he took the blender back to the dish room He took his gloves off and put new gloves on without washing his hands.
With gloved hands CK #1 went to the fridge and got the pie that was for dessert. He grabbed a knife from the drawer and began slicing the pie with the same gloved hands. He placed the sliced pie on a plate using his gloved hands. He picked up four trays and laid them on the counter. He then picked up the meal tickets and placed them on the trays.
With gloved hands CK #1 before lunch service began he reached into his pocket of his pants and pulled out a pen.
The regional director of dietary services consultant (RDDSC) told CK #1 that he needed to change his gloves. CK #1 took his gloves off and then put new gloves on without washing his hands.
With gloved hands CK #1 began plating the lunch trays for the dining room. When he ran out of the serving trays he grabbed more serving trays from the counter next to the steam table. He then took four trays and lined them up on the counter and grabbed more meal tickets and placed them on the trays. He then began plating the meal on the plate.
With gloved hands CK #1 took a meal ticket and walked out of the kitchen to ask a resident what they were ordering. When CK #1 returned to the kitchen he took his gloves off and then put new gloves on without washing his hands.
With gloved hands CK #1 grabbed a frying pan and placed it on the stove and then he went to the fridge and grabbed two pasteurized eggs. He cracked one egg into the pan and cooked the egg. He then grabbed a clean plate and placed the fried egg on the plate. He then set the plate down and cracked another egg into the pan. When the second egg was done he placed it on the plate. He then took his gloves off and then put new gloves on without washing his hands.
With gloved hands CK #1 went to the freezer and took out chicken tenders. He then placed the chicken into the fryer and wrapped up the bag and placed it back into the freezer. When the chicken tenders were done he placed them on a plate. He then grabbed a tray and placed the plate on the tray and then walked out of the kitchen. He told the staff that he was going to deliver the tray to the resident. He walked out of the kitchen. When he came back he took off his gloves and put new gloves on without washing his hands.
III. Staff interviews
The dietary manager (DM) and the RDDSC were interviewed together on 12/18/24 at 3:14 p.m. The DM said gloves should be changed between tasks. The DM said the staff should wash their hands before putting gloves on and after removing gloves. The DM said the staff should change their gloves between tasks. She said she was not sure why CK #1 was not washing his hands after disposing of their gloves and putting on a clean pair. She said she was going to provide education to the staff on hand hygiene.
Jul 2023
14 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to ensure three (#4, #45 and #43) of eight reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to ensure three (#4, #45 and #43) of eight residents reviewed for accident hazards out of 21 sample residents, were provided adequate supervision and a safe environment to prevent accidents and the re-occurrence of falls.
Specifically, the facility failed to implement effective fall precautions to prevent the re-occurrence of falls for Resident #45 and Resident #43, contributing to major injuries:
On 3/31/23 with a third fall within a week, Resident #43 fell suffering a laceration to her forehead and was sent to the emergency room for sutures; and
On 7/7/23 with a fifth fall within two months, Resident #45 fell suffering a fractured hip.
The facility further failed to ensure a physician order and adequate safety measures were followed for two-person assistance with transfers and the proper mechanical lift was used during transfers for Resident #4.
Findings include:
I. Resident #43
A. Resident status
Resident #43, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included unspecified dementia with psychotic disturbances, major depressive disorder and anxiety.
The 4/18/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview of mental status (BIMS) score of four out of 15. She required a wheelchair for mobility and one-person extensive assistance with bed mobility, transfers, dressing, bathing, toileting, personal hygiene, and locomotion. The resident had two falls since admission, one with injury and one without injury.
B. Record review
The comprehensive care plan, revised 4/18/23, revealed the resident was at risk for falls related to multiple falls. Interventions were to offer diversions, use a chair alarm, educate the resident to call for assistance before transferring, place the resident in sight of staff when awake, implement fall prevention interventions, use non-skid footwear and educate the resident to use the call light.
The July 2023 CPO revealed there were no current therapy orders for the resident and there were no physician orders for fall prevention devices.
A review of medication administration records from 3/14/23 to 4/18/23 revealed the following changes to the resident's psychotropic medications:
-Seroquel (antipsychotic) 25 MG (milligram)- give 1 tablet a day for unspecified dementia- ordered on 2/8/23 discontinued 3/26/23.
-Haldol (antipsychotic) 5 MG- give 0.5 ML (milliliter) intramuscular injection one time as needed for unspecified dementia- ordered 3/20/23 discontinued 4/8/23.
-Seroquel 25 MG- give 2 tablets a day for unspecified dementia- ordered on 3/26/23 discontinued 3/27/23.
-Ativan (benzodiazepine) 1 MG- give 1 tablet a day for unspecified dementia- ordered on 3/14/23 discontinued 3/26/23.
-Trintellix (antidepressant) 10 MG- give 1 tablet a day for major depressive disorder- ordered on 3/26/23 discontinued 3/27/23.
-Depakote (anticonvulsant) 125 MG- give 1 tablet a day for unspecified dementia- ordered on 3/26/23 discontinued 3/26/23.
-Amitriptyline (antidepressant) 25 MG- give 1 tablet every 6 hours as needed (PRN) for major depressive disorder- ordered on 3/26/23 discontinued 4/18/23.
-Hydroxyzine (antianxiety) 25 MG- give 1 tablet every 6 hours PRN for anxiety- ordered 3/26/23 discontinued 4/18/23.
-Depakote 125 MG- give 2 tablets twice a day for unspecified dementia- ordered on 3/26/23 discontinued 4/12/23.
-Amitriptyline 75 MG- give 1 tablet a day for major depressive disorder- ordered on 3/27/23 discontinued 4/4/23.
-Ativan 0.5 MG- give 1 tablet twice a day for unspecified dementia- ordered on 3/27/23 discontinued 3/27/23.
-Ativan 0.5 MG- give 1 tablet every 6 hours PRN for anxiety- ordered on 3/29/23.
-Seroquel 25 MG- give 3 tablets a day for unspecified dementia- ordered 3/27/23 discontinued 3/30/23.
-Seroquel 25 MG- give 2 tablets a day for unspecified dementia- ordered 3/30/23 discontinued 4/12/23.
-Ativan injectable solution 2 MG- inject 1 MG intramuscularly one time a day for unspecified dementia- ordered 4/12/23 discontinued 4/12/23.
-Depakote 125 MG- give 4 tablets twice a day for unspecified dementia- ordered on 4/12/23.
-Risperidone (antipsychotic) 1 MG- give 1 tablet a day for unspecified dementia- ordered on 4/13/23.
A review of the resident's fall occurrence evaluations revealed:
Fall occurrence evaluation dated 3/26/23 revealed the resident had a witnessed fall at 2:15 p.m. in the common area. The resident was sitting in her wheelchair and stood up, lost her balance and fell to the floor. No injury sustained. Interventions included to add diversionary activities, and refer to therapy. The follow up note added to the occurrence on 3/27/23 revealed an anti lock rollback device was placed on the wheelchair to prevent the chair from rolling back.
Fall occurrence evaluation dated 3/31/23 revealed the resident had a witnessed fall at 9:30 a.m. in the common area when trying to stand up and then sit back down in her wheelchair. The wheelchair rolled out from behind her and the resident fell to the floor. No injury was sustained. There was no mention why the anti lock roll back device was ineffective. Interventions were to add diversionary activities, refer to therapy and educate the staff to keep the resident in sight during waking hours. The follow up note added to the occurrence evaluation later that day revealed the resident already had a chair alarm.
Fall occurrence evaluation dated 3/31/23 revealed the resident had an unwitnessed fall at 7:15 p.m. in the private dining area. The resident was in the private dining area with two other residents but no staff. A nurse at the nurses station heard a loud noise and then observed the resident on the floor. The resident had a laceration to her forehead and was sent to the emergency room for sutures. Fall interventions were to add diversionary activities, refer to therapy and educate the staff to keep the resident in sight during waking hours.
-There was no mention why the resident had not been in the staff's sight at time of the fall. There were no new interventions added as a result of the fall.
Fall occurrence evaluation dated 4/9/23 revealed the resident had a witnessed fall at 1:45 p.m. in the common area. The resident stood up from her wheelchair at which time her chair alarm sounded and the nurse went to provide assistance. The resident was agitated, declined to sit back in her wheelchair, becoming verbally and physically aggressive with the nurse then fell as a result. The occurrence documented the fall was caused by the resident's continuous anxiety, agitation and argumentative noncompliant behavior with staff. Interventions were to add diversionary activities, refer to therapy, educate the resident to call for assistance and educate the staff to keep the resident in sight during waking hours.
Fall occurrence dated 5/30/23 revealed the resident had a witnessed fall at 4:45 a.m. in the common area. The resident had attempted to stand and walk. The resident had removed her chair alarm. Interventions were to add diversionary activities, non-skid footwear, refer to therapy, chair alarm, educate the resident to call for assistance before transferring and educate the staff to keep the resident in sight during waking hours.
A review of the physician visit notes revealed visits on 5/2/23, 5/30/23 and 6/20/23. During the physician's visits, neither the resident's frequent falls or frequent psychotropic medication changes were mentioned.
II. Resident #45
A. Resident status
Resident #45, age over 85, was admitted on [DATE]. According to the July 2023 CPO, diagnoses included unspecified dementia with anxiety and stroke.
The 6/8/23 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required a wheelchair for mobility and one-person limited assistance with bed mobility, transfers, bathing and toileting. The resident had two or more falls since admission without injury.
B. Record review
The comprehensive care plan, revised 6/8/23, revealed the resident was at risk for falls related to multiple falls, history of self transferring, and impaired cognition with decreased safety awareness. Interventions were to offer diversions, use a chair alarm, use hip protectors, fall mat to the resident's floor, educate the resident to call for assistance before transferring, place the resident in sight of staff when awake, implement fall prevention interventions, use non-skid footwear, and educate the resident to use call light.
The July 2023 CPO revealed the following physician orders:
Occupational therapy for 8 weeks to decrease fall risks to include room modification and wheelchair modification- ordered on 7/5/23.
Physical therapy for 12 weeks for therapeutic neuromuscular reeducation- ordered on 6/22/23.
-The review did not show any physician orders for fall prevention devices.
A review of the resident's fall occurrence evaluations revealed:
Fall occurrence evaluation dated 5/16/23 revealed the resident was heard yelling at 7:45 p.m. for help in her room after putting on her call light. She was found lowering herself to the floor in front of her recliner. The resident was wearing shoes. The occurrence documented the resident had been on her call light repetitively during the shift and had complained to the staff regarding the length of time it was taking for help to arrive. When the staff educated the resident to use her call light before attempting to transfer, it was documented the resident stated she had fallen because no one ever came to help her. No injuries were sustained. Interventions were to add a fall mat next to her bed, educate the resident to call for assistance, ensure the wheelchair is within reach, add non-skid footwear add non-skid strips in front of her recliner.
-There was no mention of more frequent checks or education with staff on answering her call light promptly.
Fall occurrence evaluation dated 5/30/23 revealed the resident had an unwitnessed fall at 3:30 p.m. The resident was found on the floor in her room on her hands and knees in front of her wheelchair. The resident was documented as stating she fell out of her chair. No injury was sustained. Interventions were to add diversionary activities, to add a fall mat next to her bed, educate the resident to call for assistance, ensure the wheelchair is within reach and add hip protectors.
Fall occurrence evaluation dated 6/21/23 revealed the resident had an unwitnessed fall at 11:00 p.m. The resident was found on the floor of her bathroom after turning on her call light. The fall resulted in a skin tear to the left outer arm and an abrasion to the left side of head with no bleeding. The resident had taken herself to the bathroom without assistance. Interventions were to add a fall mat next to her bed, educate the resident to call for assistance, and add non-skid footwear. Physical and occupational therapy to evaluate and treat.
-There was no mention of more frequent checks or education with staff on answering her call light promptly.
Fall occurrence evaluation dated 7/4/23 revealed the resident had an unwitnessed fall at 8:15 a.m. The staff found the resident sitting on the floor in between her bed and wheelchair. Staff concluded the resident did not use her call light for assistance and was not wearing footwear. No injuries were sustained. Interventions were to add a chair alarm, add a fall mat next to her bed, educate the resident to call for assistance, add non-skid footwear, add hip protectors, and ensure the wheelchair is within reach. The follow up note added to the occurrence evaluation revealed the resident had attempted to transfer herself and took off her alarm. It was documented she informed the staff she could do what she wanted to do and she was not going to wear hip protectors or the facility's non-skid socks.
Fall occurrence evaluation dated 7/7/23 revealed the resident had turned on her call light at 9:30 p.m. and was found in her bathroom sitting up against the wall. It was documented the resident was yelling her leg was broken and she was in pain. The resident was sent to the emergency room to evaluate and treat. The occurrence documented possible contributing factors to the fall were the resident had not used her call light, however it was documented in the occurrence the resident turned on her call light to alert the staff of her fall. Interventions were to put her bed in the low position, add a fall mat next to her bed, educate the resident to call for assistance, add non-skid footwear, add bed alarm, add hip protectors, and ensure wheelchairs within reach. The follow up note added to the occurrence evaluation revealed the resident had fractured her hip.
III. Staff interviews
Certified nurse aide with medication authority (CNA/MA) #1 was interviewed on 7/11/23 at 1:45 p.m. She stated she did not know where the fall prevention interventions for the residents were in the medical record. Registered nurse (RN) #1 attempted to assist CNA/MA #1 to locate fall prevention interventions. RN #1 stated it was in the resident's care plan but she did not know if the certified nurse aides (CNAs) had access to the residents' care plans.
CNA #7 was interviewed on 7/11/23 at 1:50 p.m. He stated fall prevention interventions were in the CNA system but he did not have access because he was still training. He had to ask the nurses or CNAs what the residents' fall interventions were. He thought there was a care plan binder at the nurse's station but was unable to find it.
CNA #1 was interviewed on 7/11/23 at 1:54 p.m. She stated she checked the resident's care plan to see the fall prevention interventions or the CNA system ([NAME]). She said Resident #43's fall interventions were a chair alarm, a fall mat, and a low bed. (A fall mat and low bed were not interventions in the resident's care plan). The fall interventions for Resident #45 were a low bed and bed alarm. (A low bed and bed alarm were not in the resident's care plan).
CNA #4 was interviewed on 7/12/23 at 10:00 a.m. She stated Resident #43 had become a high fall risk after she had numerous medication changes. She did not know what her fall interventions were. CNA #4 said the fall interventions for Resident #45 were bed and chair alarms. If there were fall interventions added to a resident's care plan, the CNAs could not see the additions. The CNAs had to ask the nurses what the fall interventions were.
The director of nursing (DON) was interviewed on 7/12/23 at 2:07 p.m. She stated the CNAs and nurses had access to the residents' care plans to find the fall interventions. There was also a communication binder kept at the nurses station for updates to residents' care. She could not answer why the staff stated they did not know about resident specific fall interventions.
IV. Facility follow-up
At the time of survey exit, 7/13/23, the NHA stated she would be able to submit documentation showing resident specific fall interventions for Resident #43 and Resident #45. The NHA sent follow up documents after survey exit on 7/14/23 at 4:24 p.m. The documentation included fall care plans for Resident #43 and Resident #45.
Resident #43's comprehensive fall care plan revealed interventions added 7/13/23 (during survey) of assisting the resident to the gazebo to look at flowers, add bed alarm, anti-roll back device on wheelchair, ensure physical needs were met, and therapy screen for safety.
Resident #45's comprehensive fall care plan revealed interventions added 7/13/23 of physical therapy to evaluate and treat.
In the NHA email communication, she revealed resident specific fall interventions were added to a communication sheet kept at the nurses station where staff, to include CNAs, were to review sheets daily and sign the sheet once they read it. The NHA was unable to provide documentation showing the particular staff who had expressed not knowing the fall interventions during the survey had signed any of the fall intervention communication sheets or were aware of the sheets' existence.
V. Failure to provide safe transfer assistance for Resident #4
A. Facility policy
The Lifting and Transferring Resident Policy, undated, was provided on 7/12/23 at 1:47 p.m. by the nursing home administrator (NHA). It read in pertinent part:
Residents are lifted and transferred safely in all instances.
-Nurses assess and determine lifting and transfer requirements and the procedure used for each resident.
-All residents must be lifted or transferred according to the determined procedure.
-Procedure appears in Resident Care Plan and Resident Profile.
-Residents who require assistance in transferring are transferred using a gait/transfer belt or with a lift.
-All members of the nursing staff, nurses, and nursing assistants are responsible for using good body mechanics, knowing the proper procedures, and properly operating assistive devices.
-Approved techniques for lifting, transfer, and body mechanics are discussed and demonstrated during each orientation program for nursing personnel.
-Mechanical lift procedures are used on any resident unable to independently pivot or transfer.
B. Resident #4 status
Resident #4, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included dementia, chronic respiratory failure, chronic obstructive pulmonary disease, and post-traumatic stress disorder (PTSD).
According to the 5/13/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident had wandering behaviors. He required total assistance for bed mobility, transfers, grooming and toilet use.
C. Record review
The care plan, initiated 11/27/21 and revised 3/5/23, identified the resident had an activities of daily living (ADL) self-care performance deficit related to cognitive impairment, history of falls, and impaired mobility. Interventions include allowing time for the resident to express feelings of frustration regarding the need for assistance in ADL tasks. Encourage the resident to use call light when assistance is needed. Sit to stand lift for transfers.
The July 2023 CPO included: staff should use an electric sit to stand lift and two persons for all transfers. Start date 6/6/23.
D. Observation
On 7/10/23 at 10:05 a.m., certified nurse aide (CNA) #7 entered Resident #4's room, closed the door and placed Resident #4 on the toilet by himself. CNA #7 did not use a sit to stand lift to transfer Resident #4 onto the toilet. CNA #7 exited the resident's room leaving Resident #4 on the toilet. CNA #7 returned approximately five minutes later and removed Resident #4 from the toilet and placed her into her recliner. CNA #7 transferred Resident #4 by himself not utilizing the sit to stand lift.
E. Interviews
Licensed practical nurse (LPN) #1 was interviewed on 7/10/23 at 10:10 a.m. LPN #1 was told of the observation. He said Resident #4 needed two person assistance with all transfers and a sit to stand was to be used on all transfers. LPN #1 said a negative outcome could be a fall, skin tear or any negative outcome.
CNA #7 was interviewed on 7/10/23 at 10:20 a.m. CNA #7 said he was somewhat familiar with Resident #4. He said Resident #4 required a lift but did not know what type of lift was required when transferring Resident #4. CNA #7 said he did not use a sit to stand lift to transfer Resident #4 and there was no lift in the resident's room.
The occupational therapist was interviewed on 7/12/23 at 10:07 a.m. The OT was told of the observation of Resident #4 on 7/10/23. He said he was just observing and assessing two CNAs with transfers of Resident #4. He said it was reported to him about the one person transfer of Resident #4 and he was reeducating CNAs on the importance of transferring a resident safely. He said the therapy department would report back to the director of nursing (DON).
The DON was interviewed on 7/12/23 at 1:13 p.m. She said it had been reported to her about the CNA transferring the resident. She said staff were supposed to familiarize themselves with the residents' care plan, [NAME] and know if the resident was a two person transfer and required a lift prior to providing resident care. She said the CNA should have not transferred the resident by themselves and reeducation was started immediately. She said a negative outcome would be a fall, skin tear or serious injury.
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 record review and interviews, the facility failed to ensure three (#17, #43 and #45) of five residents reviewed for abu...
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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 (#17, #43 and #45) of five residents reviewed for abuse out of 21 sample residents were free from abuse.
Specially, the facility failed to:
-Prevent a resident to resident altercation between Resident #43 and Resident #17; and,
-Ensure Resident #45 was free from physical abuse by a family member.
Findings include:
I. Facility policy
The Resident Safety policy, undated, was received from the nursing home administrator (NHA) on 7/11/23. It read in pertinent part:
Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends or other individuals.
II. Resident to resident physical altercation between Residents #43 and #17
A. Facility investigation
Incident 4/18/23
The incident occurred in the hallway between Resident #17 and Resident #43's rooms. The staff heard Resident #43 yelling and witnessed her hit the side of Resident #17's face. Resident #17 responded by grabbing Resident's #43's finger and biting it. The residents were separated by staff and assessed for injuries, no injuries noted.
Neither resident could recall the event when interviewed. The residents lived across the hall from each other and neither had moved as a result of the event.
The facility failed to substantiate or unsubstantiate the abuse investigation.
-However, the abuse should have been substantiated due to Resident #43 hitting Resident #17's face and Resident #17 biting Resident #43's finger.
B. Resident #17 (victim)
1. Resident status
Resident #17, age over 85, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance.
The 5/23/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview of mental status (BIMS) score of four out of 15. She required a wheelchair for mobility and had functional impairments to her lower extremities on one side. She was unable to walk and required one-person limited assistance with locomotion. No behaviors were indicated and no wandering.
2. Record review
The comprehensive care plan, revised 5/23/23, revealed the resident was at risk for elopement related to exit seeking behavior and verbalizations of wanting to leave the facility. Interventions were for the resident to wear a wander guard, periodically evaluate for continued need, offer diversions, structured activities, food, conversation, television, or books to redirect the resident. The resident required limited one-person assistance for bed mobility, transfers, locomotion, toileting, dressing, bathing, and personal hygiene.
Certified nursing assistant (CNA) tasks for behavior monitoring were reviewed on 7/11/23 and revealed no behavior monitoring for the resident.
Progress notes dated 2/13/23 through 4/18/23 revealed a behavior note dated 4/18/23 documented the resident had a physical altercation with another resident and the two residents were separated. The resident was put on 15 minute checks.
C. Resident #43 (assailant)
1. Resident status
Resident #43, age [AGE], was admitted on [DATE]. According to the July 2023 CPO, diagnoses included unspecified dementia with psychotic disturbances, major depressive disorder and anxiety.
The 4/18/23 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required a wheelchair for mobility and one-person extensive assistance with locomotion. She had hallucinations and verbal and physical aggression directed at others.
2. Record review
The comprehensive care plan, revised 4/18/23, identified the resident had behavior problems consisting of physical and verbal aggression towards others, wandering into other resident's rooms, and was at risk for abuse due to severe dementia with psychotic disturbances. Interventions included to approach the resident in a calm manner and if the resident was exhibiting behavior escalations, attempt to redirect or re-approach her later. Observe behavior episodes, determine underlying causes, divert attention, provide a quiet environment and remove the resident from the situation.
CNA task behavior monitoring reviewed on 7/11/23 for the dates 3/1/23 to 4/18/23, revealed the resident had behaviors of hitting, kicking, accusatory behavior, threatening others, and entering other resident's rooms or space.
Progress notes dated 2/13/23 through 4/18/23 revealed:
-Behavior note dated 2/13/23 revealed the resident had increased behaviors related to discontinued Ativan (anti-anxiety) and start of Seroquel (antipsychotic). The resident asked the staff to get her husband (who did not live at the facility) and was not easily redirected.
-Behavior note dated 2/14/23 revealed the resident had increased behaviors of wandering at night, taking items from other residents' rooms and from the nurses station.
-Behavior note dated 2/17/23 revealed the resident was pacing, would not stay in her bed, and entered other residents' rooms.
-Behavior note dated 2/18/23 revealed the resident continued to pace and exit seek. She was difficult to redirect.
-Behavior note dated 2/19/23 revealed the resident continued to excessively pace and go into other residents' rooms naked at times.
-Alert note dated 3/2/23 revealed the resident attempted to go into other residents' rooms looking for food and when redirected by staff, became angry and verbally aggressive.
-Alert note dated 3/3/23 revealed the resident was verbally aggressive and threatening to kill the staff. The resident also slapped a nurse in the face.
-Behavior note dated 3/5/23 revealed the resident had yelled at a nurse and threatened to kill her.
-Behavior note dated 3/6/23 revealed the resident had been fixated on a nurse and yelled and screamed at her. When the nurse refused to give the resident a cigarette, the resident began to kick and bang on the medication room door and threatened to kill the nurse.
-Behavior note dated 3/7/23 at 8:41 p.m. revealed the resident went into another resident's room, took her pants off, and urinated in the garbage can. Resident #43 had attempted to get into the male resident's bed, believing he was her husband when staff removed her.
-Behavior note dated 3/7/23 at 9:16 p.m. revealed the resident was agitated and attempted to hit a nurse.
-Alert note dated 3/8/23 revealed the resident was aggressive and threw a table top with a laptop at a nurse.
-Behavior note dated 3/10/23 revealed the resident had been wandering and attempting to go into other residents' rooms.
-Behavior note dated 3/11/23 revealed the resident believed the facility was her house and had gone into other residents' rooms to yell at them to leave.
-Alert note dated 3/12/23 revealed the resident had been agitated, attempted to exit, and threw things at the staff. She was transferred to the hospital for a mental health evaluation and returned back to the facility. It was determined she was dehydrated and required intravenous fluids.
-Behavior note dated 3/14/23 revealed the resident continued to exit seek and attempt to go into other residents' rooms.
-Alert note dated 3/20/23 revealed the resident had been hallucinating and became physically aggressive with a nurse. The resident went into another resident's room and attempted to tell the resident to leave their room. When redirected, she became physically aggressive towards staff. Intramuscular Haldol (antipsychotic) was ordered and administered to the resident by staff.
-Alert note dated 3/22/23 revealed the resident was sent out to the emergency room to be evaluated for diarrhea and dehydration with change in mental status.
-Alert note dated 3/26/23 revealed the resident had returned from the hospital. She was still experiencing visual hallucinations, agitation and making threats towards staff. Intramuscular Haldol administered.
-Order administration note dated 3/31/23 revealed the resident was given as needed (PRN) Ativan due to agitation and wandering into other residents' rooms.
- Alert note dated 4/7/23 revealed the resident had been experiencing hallucinations and attempted to pick up imaginary items off the floor.
-Fall occurrence note dated 4/9/23 revealed the resident sustained a fall without injury after becoming physically aggressive with two nurses.
-Behavior note dated 4/18/23 revealed the resident had a physical altercation with another resident and the two residents were separated. The resident was put on 15 minute checks.
III. Resident physical abuse by family member toward Resident #45
A. Facility investigation
Incident 4/13/23
The incident occurred in the resident's room at 4:00 p.m. Resident #45 came to staff and informed them the family member visiting had slapped her in the face. No injury was observed.
When interviewed, the resident's family member admitted to slapping the resident in the face because the resident was yelling at her.
The facility failed to substantiate or unsubstantiate the abuse investigation.
-However, the abuse should have been substantiated due to Resident #45 being slapped in the face by her family member.
1. Resident #45 (victim)
Resident #43, age over 85, was admitted on [DATE]. According to the July 2023 CPO, diagnoses included unspecified dementia with anxiety and stroke.
The 6/8/23 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required a wheelchair for mobility and one-person limited assistance with bed mobility, transfers, bathing, and toileting. The resident did not have any behaviors.
2. Record review
The comprehensive care plan, revised 6/8/23, revealed the resident was at risk for abuse related to recent family altercation. Interventions included removing the resident from negative situations and giving non-judgemental support, encouraging alternative communication with family such as phone calls and supervising visits with the family at all times. No behavior problems were identified in the care plan.
CNA tasks for behavior monitoring were reviewed on 7/11/23 and revealed no behavior monitoring for the resident.
Progress notes dated 3/14/23 through 4/14/23 revealed:
-Behavior note dated 4/4/23 revealed the resident was agitated with nursing staff and refused her medications. The resident hit the spoon with the medication on it out of the nurse's hand and informed the nurse she would not be taking it.
-Alert note dated 4/11/23 revealed the resident was tearful and expressed to staff her children had locked her up in a nursing facility.
-Alert note dated 4/13/23 revealed the resident had reported to the staff she had been in a physical altercation with her family member which consisted of the family member slapping her in the face. The resident denied being fearful and the family member was notified they could not visit the resident during the investigation.
-Alert note dated 4/24/23 revealed the family member resumed unsupervised visits after the resident called her and the family member apologized.
IV. Staff interview
The social services director (SSD) and the NHA were interviewed on 7/11/23 at 2:45 p.m. The SSD said if a resident's family member was on supervised visitation, he would look at what had transpired since the incident to determine with the NHA if supervised visitation needed to continue. If two residents had an altercation and were roommates or neighbors, he would ensure if it was an unsafe situation, one of the residents would be moved.
The NHA stated regarding the incident with the family member slapping Resident #45, the resident became upset after the visitation became supervised and expressed depression. The resident started to refuse to change her clothes or eat until the supervised visitation ended. The NHA had a conversation with the family member to ensure the family member understood what to do if she became upset or overwhelmed with the resident's behavior instead of slapping her.
Regarding the incident of the resident to resident altercation, Resident #43 became over stimulated and agitated and this caused her to become aggressive towards Resident #17. The staff had observed the two residents since the incident and determined it was an isolated incident and there was no need to move anyone's room.
She did not have documentation of education with Resident #45's family member regarding dementia or how to manage her stress when visiting the resident to avoid further physical abuse. She was not aware if the CNAs or nurses knew about the incident and to watch when the family member visited for signs of psychosocial distress.
CNA #4 was interviewed on 7/12/23 at 10:00 a.m. She stated Resident #43 had behaviors of delusions, hallucinations, tearfulness, verbal and physical aggression. Her aggression had decreased since May 2023 when the doctors made more medication changes.
The CNAs did not know the behavior interventions for residents unless they asked the nurses. Management did not provide the CNAs with instruction on behavior modifications.
Resident #17 had exit seeking behaviors but was not aggressive.
Resident #45 did not have behaviors.
CNA #4 was not aware of any restrictions or conflicts between Resident #45 and her family members.
Licensed practical nurse (LPN) #3 was interviewed on 7/12/23 at 1:00 p.m. She stated Resident #43 had behaviors of hallucinations, delusions, yelling out for her spouse, and wandering into other residents' rooms.
Resident #17 and #45 did not have behaviors she was aware of.
LPN #3 was not aware of any restrictions or conflicts between Resident #45 and her family members.
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 staff interviews, the facility failed to provide an ongoing program to support resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#10) of three residents reviewed for activities out of 21 sample residents.
Specifically, the facility failed to ensure Resident #10 was invited and encouraged to attend activities of her preference.
Findings include:
I. Facility policy and procedures
The Activities Program policy, undated, was provided on 7/12/23 at 1:47 p.m. by the nursing home administrator (NHA). It read in pertinent part:
Because absence of meaningful and/or enjoyable activity can lead to mental and physical deterioration in residents, the activities department will work as a member of the interdisciplinary team to keep residents functioning at the highest level possible in all dimensions of life, physical, mental, social, emotional and spiritual, (to) encourage independence and pre-institutional interests, a sense of community and self-esteem.
II. Resident status
Resident #10, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included adjustment disorder, insomnia, anxiety, and depression.
According to the 5/12/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident did not have any behaviors. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The preference for customary routine and activities revealed the resident felt it was very important to have reading materials, keep up with news, do favorite activities, and participate in church activities.
III. Record review
The care plan, initiated 5/28/21, identified the resident enjoyed activities of her choice. The resident enjoyed spending time in her room napping, reading her paper and watching soap operas. The resident was Catholic and she enjoyed praying the Rosary as well as attending the Protestant groups at times. The resident enjoyed old western and Spanish music at times. The resident enjoyed exercise class, arts and crafts and visiting in the common areas. The resident would continue to enjoy activities of her choice. Interventions include engaging the resident in conversation as often as possible, invite the resident with plenty of time to attend and offer to walk with the resident to activities.
The activity calendar for 7/10/23 listed the following:
-10:00 a.m. prayer time
-10:30 a.m. sensory group
-1:00 p.m. popcorn and a movie
The activity calendar for 7/11/23 listed the following:
-10:00 a.m. shopping
-1:00 p.m. music therapy
The activity calendar for 7/12/23 listed the following:
10:00 prayer time
10:30 exercise
11:30 reminiscing
IV. Observations
A. Observations on 7/10/23 revealed the resident did not have any meaningful activity. The resident was sitting in her wheelchair in her room at the following times: 9:30 a.m., 9:35 a.m., 10:00 a.m., 10:24 a.m., 12:40 p.m., 1:04 p.m., and 1:45 p.m.
-At 9:30 a.m., Resident #4 was sitting in her wheelchair in her room sleeping.
-At 9:35 a.m., Resident #4 was sitting in her wheelchair next to her bed.
-At 10:00 a.m., Resident #4 was sitting in her wheelchair asleep.
-At 10:24 a.m., Resident #4 was sitting in her wheelchair in her room. Resident #4 was placing personal belongings into a white bag.
-At 12:40 p.m. Resident #4 was sitting in her wheel chair sleeping. She had the white bag on her lap.
-At 1:14 p.m. no staff were observed in the area.
During the observations above, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities.
B. Observations on 7/11/23 revealed the resident did not have any meaningful activity. The resident was sitting in her wheelchair in the common area. Activity staff were getting several residents ready to go on a bus ride at 9:45 a.m. but did not invite Resident #4. Specifically, observations revealed:
-At 9:34 a.m., Resident #4 was sitting in her wheelchair in the common area.
-At 9:45 a.m., Activity staff were lining residents up to go on a bus ride
-At 9:50 a.m., Resident #4 was holding her white bag on her lap sitting in her wheelchair in the common area. No activity staff asked Resident #4 if she would like to attend the bus ride.
-At 10:00 a.m., Resident #4 self-propelled next to the nursing station while still holding her white bag on her lap.
-At 10:03 a.m., Activity staff were assisting residents to the exit and loading them onto the bus.
-At 10:07 a.m., activity staff and residents exited the building.
-At 10:34 a.m., Resident #4 was sitting in her wheelchair next to the nursing station.
-At 12:43 p.m., Resident #4 was sleeping in her wheelchair in the doorway to her room.
-At 1:07 p.m., certified nurse aide (CNA) #8 woke Resident #4 up and asked her if she wanted to listen to music. Resident #4 said, That just does not interest me and I get tired of music because that is what all activities do. CNA #8 then pushed Resident #4 into her room where she fell back to sleep.
-At 1:17 p.m., Resident #4 was sitting in her wheelchair sleeping.
During the observations above, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities.
C. Observations on 7/12/23 revealed the resident did not have any meaningful activity.
-At 9:44 a.m. Resident #4 was in the restroom in her room.
-At 10:06 a.m., the activity director (AD) was observed walking by Resident #4's room.
-At 10:09 a.m., the AD returned to the common area.
-At 10:19 a.m., residents were sitting in a common area in a circle. There were approximately 11 residents in the circle.
-At 10:24 a.m., no activities were observed in the common area.
-At 10:27 a.m., the AD started the exercise activity.
-At 10:33 a.m., three residents were observed to be participating in the exercise activity.
-At 10:36 a.m., the AD said, Oh you're not feeling it today.
-At 10:40 a.m., the exercise activity was completed and the AD started the reminiscing activity.
-At 10:45 a.m., Resident #4 was in her room sleeping.
During the observations above, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities.
V. Staff interviews
CNA #5 was interviewed on 7/12/23 at 1:08 p.m. She said activities were limited for the residents. She said all they did was play music, and that was not an activity.
The activity director (AD) was interviewed on 7/13/23 at 10:01 a.m. The AD was informed of the observations above. She said all residents should be encouraged and invited to all activities. She said, I am the only activity staff right now because my volunteer was off on a short vacation. She said for example the shopping trip was scheduled for 10:00 am on Tuesday. She said the residents did not want to go on a shopping trip so they changed it to a scenic drive but she did not have room for everyone who wanted to go. She said there were six regular seats in the van and two spots for wheelchairs. She said the residents who did not get to go didnot have an alternative structured activity.
She said there was no other activity until 1:00 p.m. She said, I would turn on the music for them before I left, and the other residents can either sit in the common area and listen to music or sit in front of the television in the common area. She said, I need to do better on inviting all residents to activities and encouraging them to participate. She said it was difficult being the only activity staff in the facility. She said the negative outcome for residents not participating in activities could be boredom, isolation, depression, negative behaviors and wandering.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure one (#7) of two residents with a pressure ulc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure one (#7) of two residents with a pressure ulcer received the necessary treatment and monitoring according to professional standards of practice out of 21 sample residents.
Specifically, the facility failed for Resident #7 to:
-Measure the pressure injury upon discovery;
-Document finding of pressure injury;
-Care plan the pressure injury; and,
-Complete a Braden scale (to assess for pressure injury risk) timely.
Findings include:
I. Professional reference
The National Pressure Injury Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 7/17/23 read in pertinent part:
Pressure Injury:
A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.
Stage 1 Pressure Injury:
Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Stage 2 Pressure Injury:
Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
Stage 3 Pressure Injury:
Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Stage 4 Pressure Injury:
Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Unstageable Pressure Injury:
Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.
II. Facility policy and procedure
The Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, was provided by the nursing home administrator (NHA) on 7/13/23 at 10:00 a.m. It revealed in part,
Assessment and Recognition-
The nurse shall describe and document/report the following:
-Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudate or necrotic tissue;
-Pain assessment;
-Resident's mobility status;
-Current treatments, including support surfaces; and,
-All active diagnoses.
III. Resident status
Resident #7, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included diabetes mellitus type II and heart failure.
The 7/7/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. She was dependent upon staff for all activities of daily living. It indicated the resident had an unstageable deep tissue injury.
IV. Record review
The July CPO included:
-Apply skin prep and an allevyn dressing to right lateral foot was ordered on 7/5/23.
The skin inspection, dated 7/6/23, noted no new skin issues observed.
The resident's electronic record, reviewed on 7/10/23, did not have:
-Measurements of the wound upon discovery;
-An updated Braden scale (a tool used to determine skin integrity);
-Any documentation of the discovery of the pressure injury; and,
-A care plan for the new pressure injury or a care plan to address the resident ' s risk for skin impairment.
V. Interviews
Licensed practical nurse (LPN) #1 was interviewed on 7/11/23 at 12:10 p.m. He said if a skin change was found for a resident, he would report the change to the charge nurse. He said the charge nurse would take a look at it, then the MDS coordinator would take a look at the injury. He said the charge nurse and the MDS coordinator were the individuals that developed the wound treatment.
LPN #1 said Resident #7 had an unstageable wound on her right lateral foot. He said the dressing was changed once a day on his shift. He said the injury was discovered recently, possibly last week but was not sure about the actual date.
The director of nursing (DON) was interviewed on 7/11/23 at 12:38 p.m. She had the MDS coordinator join in the conversation. The MDS coordinator said Resident #7 had an unstageable deep tissue injury due to crossing her feet. She said the facility had gotten an order for occupational therapy. She said the initial discovery was last Monday (7/3/23). She said the resident had an order for skin prep and Allevyn. She said she had completed an initial assessment that included measurements. She said she was sure there was a note due to her being the one who wrote the note. When told a note could not be found, the MDS coordinator left the interview.
The DON said she could not find a note and would want a note placed in the chart upon discovery for a complete and thorough record for the best care for the resident.
VI. Facility follow-up and interview
The MDS coordinator stated on 7/11/23, after the interview with the DON, that a late note was written that included the initial discovery, the initial measurements, a Brasden scale and a new care plan completed on 7/11/23.
The wound evaluation form dated 7/11/23 identified an unstageable pressure ulcer on the right lateral foot. The measurements were 2.5 cm length, 0.4 cm width, and 0.2 cm depth. There was no tunneling noted. The form identified the representative was notified on 7/11/23. The form included new orders to cleanse the area, apply Endoform and calcium alginate, cover with allevyn and change every three days and as needed if soiled.
The care plan, dated 7/11/23, identified impaired skin integrity. Interventions included:
-Complete skin inspection every seven to 10 days and as needed;
-Complete wound evaluation to monitor the progress of the resident's skin condition;
-Notify the nurse of any new areas of skin breakdown noted during bathing or daily care: redness, blisters, bruises, and discoloration;
-Pressure reducing boots to bilateral feet as tolerated. May remove for care; and
-Treatments per physician orders.
The interdisciplinary team (IDT) meeting note dated 7/12/23 identified a wound to the right foot. Nursing recommendations were heel boots at all times and therapy to work with repositioning in the wheelchair for offloading.
The Braden scale completed on 7/11/23 scored the resident at an 11, indicating Resident #7 was at moderate risk.
The DON was interviewed on 7/13/23 at 11:24 a.m. She said when a new injury is discovered, the process was to enter into the resident's electronic chart a change of condition, a wound evaluation, and measurements. She said the missing information should have been entered into the resident's electronic medical record when the wound was discovered and assessed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observations, record review and staff interviews, the facility failed to ensure residents received proper resp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#4 and #40) of two residents reviewed for supplemental oxygen use out of 21 sample residents.
Specifically, the facility failed to:
-Administer oxygen in accordance with the physician's order for Resident #4; and,
-Ensure a physician's order was in place for Resident #40's continuous oxygen use.
Findings include:
I. Facility policy
The Oxygen Administration Policy, revised October 2010, was provided on 7/12/23 at 1:47 p.m. by the nursing home administrator (NHA). It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration.
II. Resident #4
A. Resident status
Resident #4, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included dementia, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and post-traumatic stress disorder (PTSD).
According to the 5/13/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident had wandering behaviors. He required total assistance for bed mobility, transfers, grooming and toilet use. The resident received oxygen therapy.
B. Record review
The care plan, initiated 11/27/21 and revised 3/5/23, identified the resident had an impaired respiratory status related to hypoxia. Interventions included oxygen as ordered by the physician.
Provide oxygen as needed when a resident exhibits signs/symptoms of difficulty breathing, short of breath, inadequate oxygen (cyanosis), low oxygen saturation. Monitor for increased anxiety associated with shortness of breath, provide reassurance.
The July 2023 CPO included an order dated 2/6/23 for oxygen at 3 liters per minute (LPM) continuously via nasal cannula every shift due to diagnosis of COPD.
C. Observation
On 7/10/23 at 10:36 a.m. Resident #4 was sitting in her recliner with her oxygen cannula on the side of her face. The resident's oxygen concentrator was set on four liters per minute (LPM).
On 7/11/23 at 12:54 p.m. Resident #4 was sleeping in her recliner with her cannula on the side of her face.
D. Staff interviews
Licensed practical nurse (LPN) #1 was interviewed on 7/12/23 at 9:26 a.m. He said oxygen was a medication. He said the resident was supposed to be on three LPM continuously. LPN #1 went to the resident's room and stated the resident was not wearing her oxygen cannula correctly as it was on the side of her face. LPN #1 helped Resident #4 put on her cannula and exited the resident's room. He said he adjusted Resident #4's LPM to three where it should have been. He said a negative outcome could be the resident receiving too much oxygen causing hypercapnia (too much carbon dioxide in the bloodstream).
The DON was interviewed on 7/12/23 at 1:13 p.m. She said oxygen was a medication. She said Resident #4's oxygen should have been administered as the provider ordered it.
The DON said a negative outcome from not being administered oxygen when ordered could be altered mental status, dizziness, falls, and hypoxic events and could have put the residents in respiratory distress.
III. Resident #40
A. Resident status
Resident #40, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, diabetes dysphasia, and malignant neoplasm of the prostate.
According to the 7/1/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident received oxygen (02) therapy.
B. Record Review
The care plan, initiated 3/13/23, identified the resident had impaired respiratory status related to chronic obstructive pulmonary disease (COPD)/emphysema. Interventions include monitoring for increased anxiety associated with shortness of breath; provide reassurance. Monitor for signs/symptoms of respiratory distress and report to physician (increased respirations, low 02 saturation, inadequate oxygen (cyanosis), increased heart rate, restlessness, headaches, increased lethargy, increased confusion, atelectasis (collapse of lung), pleuritic pain (chest pain), accessory muscle usage). Oxygen as ordered by physician.
-The July 2023 CPO did not include a physician's order for oxygen.
C. Observation and interview
On 7/10/23 at 1:35 p.m., the resident was observed watching television in the common area. He had his portable oxygen concentrator on the back of his wheelchair and he was wearing his oxygen cannula.
On 7/11/23 at 1:39 p.m., the resident was observed in his room sitting in his wheelchair next to the bed. He was wearing his portable oxygen concentrator. Resident #40 said he had been wearing oxygen for a long time.
D. Staff interview
CNA #8 was interviewed on 7/12/23 at 9:09 a.m. CNA #8 said Resident #40 had been wearing oxygen ever since he started working at the facility, which had been approximately one year.
Licensed practical nurse (LPN) #1 was interviewed on 7/12/23 at 9:26 a.m. LPN #1 said oxygen was a medication and required a physician order. LPN #1 was told of the observations. LPN #1 checked his computer to verify the physician's order. He stated Resident #40 did not have a physician order for his oxygen. He said the resident should have had a physician order to have his oxygen on.
The DON was interviewed on 7/12/23 at 1:13 p.m. The DON said Resident #40 should have had the physician order in place for his continuous oxygen use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
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 the hospice services provided meet profe...
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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 the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#40) of two residents reviewed for hospice services out of 21 sample residents.
Specifically, the facility failed to:
-Have a written agreement for Resident #40 that included both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility; and,
-Ensure that the LTC facility staff provide orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.
Findings include:
I. Resident #40 status
Resident #40, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, diabetes, dysphasia, and malignant neoplasm of the prostate.
According to the 7/1/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident was receiving hospice services.
II. Record review
The July 2023 ordered Admit to hospice. Start date 7/7/23.
Review of the resident's medical record revealed:
-The facility did not have a care plan for Resident #40 identifying hospice care.
-The care plan failed to delineate the responsibilities of the facility versus what the hospice would provide in terms of services.
-The facility failed to have the hospice aide/nurse notes available in the resident's file at the facility.
-The facility failed to have a designated staff member with a clinical background coordinating care for the resident between the hospice agency and the facility.
III. Interviews
Certified nurse aide (CNA) #8 was interviewed on 7/12/23 at 9:09 a.m. He said he was not aware Resident #40 was receiving hospice care.
Licensed practical nurse (LPN) #1 was interviewed on 7/12/23 at 9:26 a.m. He said hospice was providing services but did not know what their schedule was and when they came into the facility. He said he had never spoken with anyone from hospice, and said there was not a hospice book at the nursing station.
CNA #1 was interviewed on 7/12/23 at 9:48 a.m. She said the resident was on hospice but she did not know when hospice was supposed to be in the facility. She said she did not know anything about a hospice book.
The director of nursing (DON) was interviewed on 7/12/23 at 1:13 p.m. The DON said she was not familiar with the regulation specific toward hospice care. She said she thought social services was the coordinator between hospice providers but she was not for sure. She said the facility had no formal orientation for hospice aides or nurses. The DON said the facility should have had a care plan delineating the responsibilities of the facility versus what the hospice would provide in terms of services.
The hospice director (HD) was interviewed on 7/13/23 at 11:01 a.m. The HD said the registered nurse (RN) was in the facility on 7/12/23. She said the RN was in the facility every other week or as needed (PRN). She said the facility had not provided any orientation other than a tour of the facility by facility staff. She said the RN had just dropped off the hospice notebook yesterday when she visited the facility. The HD said hospice had their own care plan and did not share a care plan with the facility. The HD said they have been providing hospice services since 6/23/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNAs) consisted of annual training for dementia management and abuse prohibition tra...
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Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNAs) consisted of annual training for dementia management and abuse prohibition training.
Specifically, the facility:
-Failed to ensure CNAs received dementia management training for two of five CNAs; and
-Failed to ensure CNAs received abuse prohibition training for two of five CNAs.
Findings include:
I. Training review
Five CNAs were reviewed for the annual required dementia management training. Training records revealed two (CNA #3 and CNA #6) of the five CNAs reviewed did not have the required annual dementia training.
Five CNAs were reviewed for the annual required abuse training. Training records revealed two (CNA #3 and CNA #6) of the five CNAs reviewed did not have the required annual abuse training.
II. Interview
The nursing home administrator (NHA) was interviewed on 7/11/23 at 2:15 p.m. She said the facility had planned a skills school for August 2023 to include abuse and dementia training for the staff. She said the facility did not have current training for the current staff identified. She said it was important to ensure staff had the correct training to provide the best care to the residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to comprehensively assess and care plan the continued us...
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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 comprehensively assess and care plan the continued use of personal alarms and wander guards as potential restraints for three (#17, #43 and #14) of eight residents reviewed for physical restraints out of 21 sample residents.
Specifically, the facility failed to:
-Obtain orders and consents for alarms prior to their application for Resident #17 and #43; and,
-Review and ensure the necessity for continued use of alarms was not for staff convenience for Residents #17, #43 and #14.
Findings include:
I. Facility policy
The Wander Guard policy, undated, was provided by the nursing home administrator (NHA) on 7/12/23 at 11:04 a.m. It read in pertinent part:
Two separate orders will be placed in the electronic medical record when a wander guard order has been obtained:
Order will state for the nursing staff to check for placement function every shift and order will state for nursing staff to check for expiration date weekly.
II. Resident #17
A. Resident status
Resident #17, age over 85, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance.
The 5/23/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview of mental status (BIMS) score of four out of 15. She required a wheelchair for mobility and had functional impairments to her lower extremities on one side. She was unable to walk and required one-person limited assistance with locomotion. No behaviors were indicated and no wandering. The resident had a bed alarm, chair alarm and a wander guard alarm.
B. Observations
Resident #17 was observed on 7/12/23 at 9:21 a.m. Resident #17 was sitting in the front lobby by the nurses station. A wander guard alarm was visible around her ankle. During observation, the resident did not make any attempts to elope or stand up out of her chair setting off the alarms.
C. Record review
The comprehensive care plan, revised 5/23/23, revealed the resident was at risk for elopement related to exit seeking behavior and verbalizations of wanting to leave the facility. Interventions were for the resident to wear a wander guard, periodically evaluate for continued need, offer diversions, structured activities, food, conversation, television, or books to redirect the resident. The resident required assistance from staff to complete activities of daily living (ADL) to include bed mobility and locomotion. The resident was at risk for falls related to cognitive impairment and interventions included to keep the alarm boxes out of her reach and to have alarm on at all times.
-The care plan did not specify if these were chair or bed alarms.
The July 2023 CPO revealed the following physician orders:
Wander guard at all times related to exit seeking- ordered on 6/7/23.
Behavior monitoring for the following behaviors related to wander guard: wandering outside of facility- ordered on 6/25/23.
-The CPO reviewed from 1/27/23 to 7/10/23 failed to reveal physician orders for a bed alarm or chair alarm.
The resident's medical record revealed a verbal consent from the power of attorney (POA) for a bed and chair alarm dated 10/9/21, two days after her date of admission [DATE]. The consent form documented least restrictive measures would be tried first and a physician's order would be obtained (no order was located). A verbal consent from the POA for a wander guard dated 1/10/22 was in the record. The consent form documented the resident would be re-evaluated quarterly for the need of the wander guard.
An elopement evaluation dated 5/26/23 revealed the resident was physically capable of leaving the facility, she had a history of wandering and elopement attempts and verbalized wanting to leave.
-No other elopement evaluations were located in the resident's medical record.
Progress notes reviewed from 4/29/23 to 7/10/23 failed to reveal any periodic or quarterly reviews of the resident's chair, bed or wander guard alarms.
III. Resident #43
A. Resident status
Resident #43, age [AGE], was admitted on [DATE]. According to the July 2023 CPO, diagnoses included unspecified dementia with psychotic disturbances, major depressive disorder and anxiety.
The 4/18/23 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required a wheelchair for mobility and one-person extensive assistance with locomotion. She had hallucinations and verbal and physical aggression directed at others but no wandering indicated. The resident had a bed alarm, chair alarm and a wander guard alarm.
B. Observations
Resident #43 was observed on 7/11/23 from 8:58 a.m. to 9:44 a.m. Resident #43 was sitting by a water fountain in the front lobby. A wander guard alarm was visible around her ankle. During observation, the resident did not make any attempts to elope or stand up out of her chair setting off the alarms.
C. Record review
The comprehensive care plan, revised 4/18/23, revealed the resident was at risk for elopement related to exit seeking behavior and verbalizations of wanting to leave the facility. Interventions were for the resident to wear a wander guard, periodically evaluate the wander guard for continued need, offer diversions, structured activities, food, conversation, television, or books to redirect the resident. The facility was to set up a meeting with the family to determine if the resident may need a more appropriate facility if elopement attempts continue. The resident required assistance from staff to complete ADLs to include locomotion. The resident was at risk for falls related to multiple falls and interventions included chair alarm.
-The care plan did not identify a bed alarm.
The July 2023 CPO revealed the following physician orders:
Wander guard at all times related to exit seeking- ordered on 6/7/23.
Behavior monitoring for the following behaviors related to wander guard: wandering outside of facility- ordered on 6/25/23.
-The CPO reviewed from 3/26/23 to 7/10/23 failed to reveal physician orders for a bed alarm or chair alarm.
-Review of the resident's medical record for a wander guard consent, bed alarm consent and chair alarm consent were not located.
An elopement evaluation dated 6/27/23 revealed the resident was physically capable of leaving the facility, she had a history of wandering and elopement attempts and verbalized wanting to leave.
-No other elopement evaluations were located in the resident's medical record.
Progress notes reviewed from 2/6/23 to 7/10/23 failed to reveal any periodic or quarterly reviews of the resident chair, bed or wander guard alarms.
IV. Staff interviews
Certified nurse aide (CNA) #1 was interviewed on 7/11/23 at 1:54 p.m. She stated Resident #43 did not make attempts to elope any more because she was too physically weak. It had been at least three months since she had been an elopement risk.
Resident #17 verbally expressed a desire to leave but was not physically capable of eloping.
The bed and chair alarms were to notify the staff when the resident got up from her chair or bed.
CNA #4 was interviewed on 7/12/23 at 10:00 a.m. CNA #4 stated Resident #43 did not make attempts to elope from the facility. She had a wander guard, a chair alarm and a bed alarm. The alarms were to notify the staff when she got up from her bed or chair and where she was.
Resident #17 did verbally express a desire to leave the facility and would try to go to the exit doors but was not physically capable of leaving. She had a bed alarm and a chair alarm because she was a fall risk. The alarms let the staff know when she got up from her bed or chair and they needed to check on her in her room.
Licensed practical nurse (LPN) #3 was interviewed on 7/12/23 at 1:00 p.m. Resident #43 did not make attempts to elope from the facility, just verbalized distress when her husband was not there visiting. She had a wander guard, a chair alarm, and a bed alarm. The alarms were to notify the staff when she got up from her bed or chair and where she was.
LPN #3 had not seen Resident #17 attempt to elope. She had a bed alarm and a chair because she was a fall risk and the alarms let the staff know when she got up.
The NHA and director of nursing (DON) were interviewed on 7/12/23 at 2:07 p.m. The NHA stated before a wander guard alarm, bed alarm or chair alarm could be used for a resident, there needed to be an order, a consent and monitoring put into place. Chair and bed alarms were used to notify the staff when a resident got up from their chair or bed and alert the staff to check on the resident. Alarms needed to be reviewed quarterly for necessity. The elopement evaluations were in the resident's medical record.
V. Facility follow-up
The NHA provided requested documentation on 7/12/23 at 5:30 p.m. that included:
A signed consent by the POA for Resident #43 to have a bed alarm and chair alarm dated 4/3/23.
-However, no physician orders were provided for the alarms.
A verbal consent given by the POA for Resident #43 to have a wander guard alarm dated 2/10/23.
-However, a physician order was not obtained until 6/1/23.
A physician's order for a bed and chair alarm for Resident #17 dated 7/12/23 (during survey).
-However, the alarms were initially put into place 10/9/21.
VI. Resident #14
A. Resident status
Resident #14, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included diabetes mellitus, dementia and insomnia.
According to the 6/10/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident had disorganized thinking and had difficulty focusing attention. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident's restraint assessment did not document use of a bed alarm.
B. Observation
Resident #14 was lying in bed sleeping on 7/11/23 at 3:41 p.m. The bed alarm was placed on the left side underneath the resident's mattress.
Resident #14 was lying in bed sleeping on 7/12/23 at 9:30 a.m. The bed alarm was placed on the left side underneath the resident's mattress.
C. Record review
The care plan, initiated 1/25/21 and revised 3/16/23, identified the resident was at risk for falls related to a history of falls and self-transferring. Interventions include maintaining call light within reach. Educate the resident to use call light. Place alarm boxes out of resident reach. Implement preventative fall interventions/devices. Pressure alarm to bed.
-The resident did not have a physician's order for the bed alarm.
-A bed alarm assessment, interdisciplinary notes, and risk benefit statement were requested during the survey. They were not provided at time of exit on 7/13/23.
D. Staff interviews
Certified nurse aide (CNA) #1 was interviewed on 7/11/23 at 9:44 a.m. She said she was familiar with Resident #14. She said Resident #14 did not have any fall interventions in place.
CNA #8 was interviewed on 7/11/23 at 1:12 p.m. He said Resident #14 did not have any fall interventions that he was aware of.
Licensed practical nurse (LPN) #1 was interviewed on 7/11/23 at 1:24 p.m. He said the resident had a history of falls. He said the bed alarm was to alert staff in the event Resident #14 was trying to self-transfer out of bed.
Certified nurse aide with medication authority (CNA/MA) #3 was interviewed on 7/12/23 at 9:44 a.m. She Resident #14 had a bed alarm and was supposed to have her bed in a low position. She said the bed alarm was in place to alert staff when Resident #14 was getting up and hopefully they got there in time.
The nursing home administrator (NHA) and interim director of nursing (IDON) were interviewed on 7/12/23 at 2:31 p.m. The NHA said when an alarm was used for a resident, the interdisciplinary team (IDT) would assess if the alarm was necessary, a physician's order was in place, consent and a care plan documenting the alarm would have been in place prior to the alarm being installed. The NHA was told of the interviews and observations above. She said, We look at the safety of each resident and placement of the bed alarms. She said the bed alarm for Resident #14 was in place to alert the staff when the resident was trying to get out of bed. She said, I do not like alarms and it is my goal to remove all alarms from the facility. She said the alarms were counterproductive because they could startle a resident and annoy other residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on th...
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Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews for three of five certified nurse aides (CNAs) reviewed.
Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for CNA #2, CNA #4 and CNA #6.
Findings include:
I. Record review
CNA #2 (hired 8/1/19) , CNA #4 (hired 3/30/2020) and CNA #6 (hired 6/8/22) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review.
II. Interview
The director of nursing (DON) was interviewed on 7/11/23 at 3:15 p.m. She said the facility had not completed any annual performance reviews, but did have a plan going forward to complete the reviews by August 2023.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** VI. Resident #36
A. Resident status
Resident #36, over the age of 65, was admitted on [DATE] and readmitted on [DATE]. According...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** VI. Resident #36
A. Resident status
Resident #36, over the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 CPO, diagnoses included anorexia, chronic ischemic heart disease, muscle weakness, anxiety disorder and restless legs syndrome.
The 5/26/23 MDS assessment revealed the resident had a severe cognitive impairment ability with a BIMS score of four out of 15. She required extensive assistance of two-person with transfers and toileting. One person assistance with dressing, and personal care. There were no behaviors and rejection of care.
B. Observation
Resident #36 was observed on 7/12/23 at approximately 1:15 p.m. at a group musical activity. The resident started yelling out for help and a staff member notified CNA/MA #1. The resident was given her afternoon medication but continued to yell out for help. CNA/MA #1 assisted the resident to her room momentarily.
At 1:28 p.m. CNA/MA #1 brought the resident back to the nursing station. The resident continued to yell out for her mother.
At 1:35 p.m. CNA/MA #1 notified the NHA about the resident's behaviors. The NHA who was also a registered nurse assisted the resident to her room and completed a physical assessment of the resident.
At 1:42 p.m. the resident was brought back to the nursing station and she continued to call for her mother to help her.
At 1:46 p.m. CNA/MA #1 assisted the resident to her room and left her with a call light in the resident's reach. The resident's behavior intensified, crying out loud for help. The resident remained in her wheelchair crying for help.
At 2:15 pm, CNA #10 arrived to transfer the resident into bed. The resident then stopped crying for help.
C. Record review
The care plan, initiated 9/30/22 revealed Resident #36 was taking Zoloft 1 tablet 25 milligrams one time a day for anxiety disorder. The interventions included to monitor for and report to physician/PA (physician assistant) adverse effects of antidepressant medication use ( suicidal ideations, worsening depression, panic attacks, irritability, monitor for signs of mood changes or distress and monitoring patient health questionnaire (PHQ-9).
The care plan did not include non pharmacological interventions for the resident.
The July 2023 CPO documented the following: Zoloft oral tablet 25 (mg) 1 tablet a day related to anxiety disorder with a start date of 6/13/23.
-The MAR and TAR did not include behavioral tracking for the use of Zoloft for anxiety and behavior disorder.
D. Staff interviews
CNA #10 was interviewed on 7/12/23 at 2:20 p.m. The CNA said the resident did not like sitting up in her wheelchair and would have a behavior outburst when left in her wheelchair. The CNA said the staff should assist the resident to bed as she was on her break at the time the resident was yelling for help. CNA #10 said the resident usually had behaviors when she became anxious. The CNA said the resident usually calms down when she was positioned in her recliner in her room or assisted to bed.
CNA/MA #1 was interviewed on 7/12/23 at 2:35 p.m. The CNA/MA said the resident was complaining about her colostomy bag and stomach pain. The CNA/MA said the resident was assessed by the NHA and the resident was included on the list of residents who were to be seen by the visiting physician later that afternoon. The CNA/MA said the resident frequently exhibited destructive behaviors and she was on medication to help calm her down.
The nursing home administrator (NHA) was interviewed on 7/12/23 at 2:46 p.m. The NHA said the resident had frequent behaviors when she became anxious. She said the resident was taking Zoloft 25 mg, 1 tablet a day for anxiety. The NHA said the interdisciplinary team (IDT) meets to discuss psychotropic medications which were entered on the medication and treatment administration (MAR and TAR) to track behaviors to ensure the effectiveness of the medications. The NHA said the facility had not been monitoring Resident #35 behaviors and could not tell how often the resident has those behaviors and the effectiveness of her antidepressant medications. The NHA said the nursing should be tracking Resident #35 behaviors and provide non-pharmacological interventions prior to administering her anxiety medication.
Based on record review and interviews, the facility failed to ensure three (#43, #201 and #36) of eight residents were free from unnecessary psychotropic medications out of 21 sample residents.
Specifically, the facility failed to:
-Monitor targeted behaviors for psychotropic medications for Residents #43, #102, and #36;
-Ensure consents were obtained prior to medication administration for Residents #43 and #201; and,
-Ensure as needed (PRN) orders did not extend 14 days without documented clinical rationale from the physician or a physician evaluation of the resident for Residents #43 and #201.
Findings include:
I. Facility policy
The Psychotropic Medication Use policy dated July 2022, was provided by the nursing home administrator (NHA) on 7/12/23 at 11:04 a.m. It read in pertinent part:
Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.
PRN psychotropic medications are limited to 14 days. For psychotropic medications that are not antipsychotics: if the prescriber or the attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. For psychotropic medications that are antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication.
II. Resident #43
A. Resident status
Resident #43, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included unspecified dementia with psychotic disturbances, major depressive disorder, and anxiety.
The 4/18/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview of mental status (BIMS) score of four out of 15. She required a wheelchair for mobility and one-person extensive assistance with locomotion. She had hallucinations and verbal and physical aggression directed at others.
B. Record review
The comprehensive care plan, revised 4/18/23, revealed the resident was taking an anticonvulsant medication for dementia, a benzodiazepine medication for anxiety, and an antipsychotic medication for dementia. Interventions were to consult with the physician and pharmacist for dose reductions, monitor for side effects, monitor for worsening signs of depression, and review risk and benefits with the family.
The July 2023 CPO revealed the following physician orders:
-Monitor for behaviors related to Seroquel (antipsychotic) such as hitting and aggression- ordered on 3/28/23 (resident stopped taking this medication 4/12/23).
-Lorazepam (benzodiazepine) 0.5 MG (milligrams)- give 1 tablet by mouth every 6 hours as needed (PRN) for anxiety - ordered on 3/29/23.
-Depakote (anticonvulsant) 125 MG- give 4 capsules by mouth two times a day for unspecified dementia- ordered on 4/12/23.
-Monitor for behavior related to Depakote such as physical aggression- ordered on 4/13/23.
-Risperidone (antipsychotic) 1 MG- give 1 tablet by mouth for unspecified dementia- ordered on 4/13/23.
-An order for behavior tracking for the Risperidone was not located.
A review of the resident medication administration records (MAR) from 3/1/23 to 7/1/23 revealed:
-The resident had originally started Lorazepam on 3/14/23 before dose change on 3/29/23.
-The resident had originally started Depakote on 3/26/23 before dose change on 4/12/23.
-The resident had not been prescribed Seroquel since 4/14/23.
-The resident had a one-time order on 3/21/23 for Haldol (antipsychotic) 2 MG intramuscular injection for unspecified dementia. Haldol was administered 3/21/23, 3/26/23, and 4/8/23.
A review of scanned documents in the resident's medical record revealed a signed consent from the power of attorney (POA) for Depakote dated 4/3/23 (start date of medication was 3/26/23), a signed consent from the POA for Risperidone dated 4/13/23, and a signed consent from the POA for Lorazepam dated 4/3/23 (start date of medication was 3/14/23).
-There was no consent located for the injectable Haldol from the POA.
A review of progress notes dated 3/21/23 to 7/10/23 revealed:
Order administration notes dated 3/21/23 revealed PRN intramuscular Haldol 2 MG was requested from the physician for physical aggression. The injection was administered and effective.
Order administration notes dated 3/26/23 at 6:40 p.m. revealed PRN intramuscular Haldol 2 MG was administered after the resident returned from a hospitalization due to low potassium. The resident was unsteady on her feet, appeared sedated and was having hallucinations.
Fall occurrence progress note dated 3/26/23 at 8:10 p.m. revealed the resident attempted to stand in the common area and lost her balance resulting in a fall.
Social services assessment note dated 4/17/23 revealed the resident had two doses of intramuscular Haldol for unmanageable behaviors.
Order administration notes revealed PRN Lorazepam was administered between 4/8/23 and 7/10/23, 31 times without a documented non pharmalogical intervention tried and failed first. There were only two order administration notes within this time frame where non pharmological interventions were tried with the resident.
-There were no progress notes located documenting a consent being given by the POA for the injectable Haldol.
-There were no progress notes located documenting the reason injectable Haldol was administered on 4/8/23.
Medication regimen review from the pharmacist dated 4/4/23 revealed documentation was needed for the clinical rationale if continuing the PRN Lorazepam after 14 days.
-There were no physician visit notes or progress notes between 4/8/23 to 7/10/23 documenting the necessity for the extended use of the PRN Lorazepam after the 14-day period.
III. Resident #201
A. Resident status
Resident #201, age [AGE], was admitted on [DATE]. According to the July 2023 CPO, diagnoses included unspecified dementia with agitation.
The 6/21/23 MDS assessment had not been done. No other MDS assessments were located in the resident's record.
B. Record review
The comprehensive care plan, initiated 6/23/23, revealed the resident was taking a scheduled antipsychotic medication for dementia. Interventions were to consult with the physician and pharmacist for dose reductions, monitor for side effects, monitor for worsening signs of depression, and review risk and benefits with the family.
-There was no care plan focus for PRN antipsychotics.
The July 2023 CPO revealed the following physician orders:
-Monitor for behaviors related to Seroquel (antipsychotic) such as hitting - ordered on 6/21/23 (resident stopped taking this medication 6/22/23).
-Haldol (antipsychotic) 1 MG- give 1 tablet by mouth every 6 hours as needed for anxiety or aggression - ordered on 6/22/23.
-Monitor for behaviors related to Haldol such as yelling- ordered on 6/22/23.
-Risperidone (antipsychotic) 0.5 MG- give 1 tablet by mouth for unspecified dementia- ordered on 6/29/23.
-An order for behavior tracking for the Risperidone was not located.
A review of the resident MARs from 6/1/23 to 7/10/23 revealed:
-The resident had originally started Risperidone on 6/22/23;
-The resident had not been prescribed Seroquel since 6/22/23.
A review of scanned documents in the resident's medical record revealed a signed consent from the power of attorney (POA) for Risperidone dated 6/29/23 (start date of medication was 6/22/23).
-No consent form was located for the Haldol PRN.
A review of progress notes dated 6/21/23 to 7/10/23 revealed:
Order administration note dated 7/3/23 at 1:05 p.m. revealed the resident received a PRN dose of Haldol for an x-ray.
Order administration note dated 7/3/23 at 4:03 p.m. revealed the resident received a PRN dose of Haldol. No indication or non pharmological interventions were documented. The PRN was given less than 6 hours since the last dosage, contrary to the physician order.
-There were no physician visit notes or progress notes between 6/21/23 and 7/10/23 documenting the necessity for the extended use of the PRN Haldol after the 14-day period.
IV. Staff interviews
Licensed practical nurse (LPN) #3 and registered nurse (RN) #2 were interviewed on 7/12/23 at 1:00 p.m. LPN #3 stated when the nurse gives a PRN psychotropic medication to a resident, they need to attempt a non pharmalogical intervention first and document if it was successful or not before administering the medication. For PRN medications like Lorazepam, a new order is required from the physical every 14 days and there should be a physician's visit note in the medical record documenting the rationale for the extension. For Resident #201 and Resident #43, LPN #3 was unable to find physician visit notes in the medical records regarding extending their PRN psychotropic. LPN #3 did not know the requirement to extend a PRN antipsychotic such as Haldol.
RN #2 stated she did not know the requirement to extend a PRN antipsychotic such as Haldol.
The NHA and director of nursing (DON) were interviewed on 7/12/23 at 2:07 p.m. The NHA stated when a new resident is admitted to the facility, if the resident is taking psychotropic medications, behavior monitoring is started. The DON put the behaviors and non pharmological interventions in the communication binder for the staff to read. The facility must obtain consents from the resident's responsible party or from the resident for all psychotropic medications. When a nurse administered a PRN psychotropic medication to a resident, a non pharmological intervention must be tried first and if the intervention was ineffective, there must be documentation in the progress notes before the PRN medication was given. PRN psychotropic medications given for anxiety, like Lorazepam, required a new order and clinical rationale from the physician to continue as a PRN. A PRN antipsychotic medication, like Haldol, required a new order, and an assessment by the physician and then documented clinical rationale for continued PRN usage. The NHA and DON acknowledged the PRN psychotropic medications for Resident #201 and Resident #43 should have consents and should have been reviewed after every 14 days if continued.
V. Facility follow up
On 7/12/23 at 5:30 p.m. the NHA provided a verbal consent for Depakote from the POA for Resident #43 dated 7/12/23 (medication was started 3/26/23), a signed consent for Risperdal from the POA for Resident #201 dated 6/29/23 (medication was started 6/22/23), and a verbal consent for Haldol from the POA for Resident #201 dated 7/11/23 (medication was started 6/22/23).
-No physician rational or physician evaluation was provided for the extended use of the PRN for Resident #43 or Resident #201.
-No consent for the intermuscular PRN Haldol for Resident #43 was provided.
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 drugs and biologicals were labeled and stored in accordance with accepted professional standards, in two of two medication carts and...
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Based on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in two of two medication carts and one of one medication storage rooms.
Specifically, the facility
-Failed to date an Anoro ellipta inhaler;
-Failed to date two vials of tuberculin when opened;
-Failed to discard an expired Victoza pen; and,
-Failed to discard an unknown pill in a plastic cup in the medication cart.
Findings include:
I. Professional references
According to the Anoro Ellipta inhaler website, retrieved 7/17/23 from: https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Anoro_Ellipta/pdf/ANORO-ELLIPTA-PI-PIL-IFU.PDF, Discard ANORO ELLIPTA 6 weeks after opening the foil tray or when the counter reads '0' (after all blisters have been used), whichever comes first. The inhaler is not reusable. Do not attempt to take the inhaler apart.
According to the Tubersol package insert, retrieved 1/25/23 from: https://www.fda.gov/media/74866/download, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded.
According to the Victoza insulin pen website, retrieved 7/17/23 from: https://www.novo-pi.com/victoza.pdf, After first use of the VICTOZA pen, the pen can be stored for 30 days at controlled room temperature (59°F to 86°F) or in a refrigerator (36°F to 46°F).
II. Facility policy
The Medication Storage policy, revised February 2023, provided by the nursing home administrator (NHA) on 7/11/23 at 1:08 p.m. included, multi-dose vials that have been opened of accessed (needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.
III. Observations and interviews
The medication cart for halls A and B on 7/10/23 at 10:15 a.m. had an Anoro inhaler that had not been dated when opened and an unknown pill in a plastic cup.
Registered nurse (RN) #1 said the inhaler was not opened on her shift and she did not know what the pill was. She said it was important to ensure the safety of the medication for the resident.
The medication storage room on 7/10/23 at 10:20 a.m. had two open multi-dose tuberculin vials without an open date.
RN #1 said the vials should have been dated when opened.
The medication cart for halls E and F on 7/11/23 at 9:43 a.m. had a Victoza insulin pen with an open date of 6/9/23.
Licensed practical nurse (LPN) #1 said he was not aware the pen was expired. He said the pen should have been discarded after 30 days of opening. He said it was important to discard the pen after 30 days of opening to make sure the medication was effective.
IV. Interview
The director of nursing (DON) was interviewed on 7/13/23 at 11:24 a.m. She said it was standard of practice to date medications when opened for the safety of the residents, to discard expired medications for the safety of the residents and to discard an unknown pill when found. She said it was important to ensure no harmful effects happen to the residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen.
Specifically, the facility faile...
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Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen.
Specifically, the facility failed to ensure cutting boards were free from deep scratches and stains.
Findings include:
I. Professional reference
According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized.
II. Observation
The initial kitchen tour conducted on 7/10/23 at 9:30 a.m. revealed four large plastic cutting boards. There were brown, green, red, and large white cutting boards on the serving line. All the cutting boards were heavily scored and stained.
On 7/11/23 at 9:06 a.m., dietary aide (DA) #2 was cutting bread on the plastic brown cutting board.
On 7/12/23 11:15 a.m. DA #4 was observed cutting tomatoes on the green cutting board.
III. Staff interview
The dietary manager (DM) was interviewed on 7/13/23 at 9:56 a.m. The DM was told of the observations of the cutting boards in the kitchen. He said the cutting boards were visibly stained and showed wear. He said he would replace them immediately. He said the deep scratches could be a potential for bacteria to grow.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observations, record reviews and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the devel...
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Based on observations, record reviews and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections for residents.
Specifically, the facility failed to ensure:
-Ensure staff offered residents hand hygiene appropriately; and,
-Ensure proper hand hygiene standards were followed by staff during dining service.
Findings include:
I. Facility policies and procedures
The Handwashing and Hand Hygiene policy, undated, was provided by the director of nursing (DON) on 7/12/23 at 3:30 p.m. It read in pertinent part:
Proper hand washing technique is used for the prevention of transmission of infectious diseases.
All personnel working in the facility were required to wash their hands before and after a resident's contact, before and after performing any procedure, after sneezing or blowing noses, and after physical contact.
-Hand sanitizing wipes or sanitizer will be available at all table settings.
-Staff will encourage residents to utilize hand sanitizing wipes to prevent infections.
-Residents who need assistance will be assisted by nursing and dietary staff.
II. Observations
On 7/11/23 at 11:20 a.m., residents started arriving at the dining room for lunch. The meal served for lunch were tacos, fresh fruits and cupcakes for dessert. Most of the residents were wheeling themselves with their hands to the dining room and others were being assisted by the facility staff.
-At 11:35 a.m. the dietary aides and nursing staff started serving water and beverages. A few of the residents required assistance with eating and were being assisted by staff.
-At 11:50 a.m. Resident #35 arrived at the dining room wheeling himself by touching and rolling the wheels on his wheelchair with his hands.
Resident #35 was served his lunch, however, the staff did not offer hand hygiene to the resident. Though the resident had silverware, he started eating with his hands without any form of hand hygiene. There were no hand sanitizing wipes on any of the dining tables.
None of the residents were offered hand hygiene before and after lunch.
On 7/12/23 at 12:15 p.m. certified nurse aide (CNA) #9 was assisting a resident with eating. The CNA noticed that another resident needed assistance with her oxygen cannula. The CNA assisted the resident by touching and adjusting the oxygen cannula by the tip of the tube, therefore, touching the nostril of the resident with oxygen. The CNA proceeded to the table and continued assisting the other resident without performing hand hygiene.
III. Staff interviews
Dietary aide (DA) #3 was interviewed on 7/12/23 at 1:10 p.m. The DA said performing hand hygiene was very important to prevent the transmission of infectious diseases. The DA said the residents should be provided with hand hygiene before and after meals. The DA said the facility had not been consistent with providing hand sanitizing wipes for the residents. The DA said the current practice could lead to the spread of infectious diseases.
CNA #9 was interviewed on 7/12/23 at 1:30 p.m. The CNA said every resident should be offered hand hygiene before and after each meal to prevent the spread of infectious diseases. She said some of the residents were able to wheel themselves to the dining room by rolling the wheels of their wheelchairs with their hands and should be offered hand hygiene before meals. CNA #9 said she should have performed hand hygiene after assisting the resident with the oxygen cannula before proceeding to continue to assist the other resident with their meal. The CNA said she had a pocket hand sanitizer in her pocket but forgot to use it. She said performing hand hygiene after coming into contact with a resident could prevent the spread of infectious diseases.
The director of nursing (DON) was interviewed on 7/12/23 at 2:15 p.m. The DON said the staff should follow the general guidelines of performing hand hygiene before and after assisting residents with care. She said residents should be offered hand hygiene before and after meals.The DON said staff were trained to utilize the hand sanitizing stations available throughout the facility and to carry a small pocket hand sanitizing gel with them at all times. The DON said the current practice could lead to the spread of germs and infectious diseases.
The nursing home administrator (NHA) was interviewed on 7/12/23 at 2:15 p.m. The NHA said the staff were trained to perform proper hand hygiene and to offer hand hygiene to all residents before and after meals. The NHA said the facility would provide education to the nursing staff and dietary aides on hand hygiene.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
Based on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identifie...
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Based on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, facility assessments, and described in the plan of care for three of five certified nurse aides (CNAs), two of two licensed practical nurses (LPNs) and two of two registered nurses (RNs).
Specifically, the facility:
-Failed to complete competencies as identified in the facility assessment for CNA #2, #4, and #6;
-Failed to complete competencies as identified in the facility assessment for LPN #1 and #2; and
-Failed to complete competencies as identified in the facility assessment for RN #1 and #2.
I. Facility assessment
The facility assessment, reviewed 1/8/23, identified the staff training provided by the facility to meet the needs of the residents, which read in pertinent part:
Staff training/education and competencies
Training Topics:
Communication - effective communications for direct care staff
Resident's rights and facility responsibilities - ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents
Abuse, neglect, and exploitation - training that at a minimum educates staff on- (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or the misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention.
Infection control - a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program
Culture change (that is, person-centered and person-directed care)
Required in-service training for nurse aides. In-service training must:
-Be sufficient to ensure the continuing competence of nurse aides and all staff but must be no less than 12 hours per year.
-Include dementia management training and resident abuse prevention training.
-Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff.
-For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Required training of feeding assistants - through a State-approved training program for feeding assistants
Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life
Cultural competency (ability of organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of residents)
Person-centered care - This should include but not be limited to person-centered care planning, education of resident and family /resident representative about treatments and medications, documentation of resident treatment preferences, end-of-life care, and advance care planning
Activities of daily living - bathing (e.g., tub, shower, sitz, bed), bed-making (occupied and unoccupied), bedpan, dressing, feeding, nail and hair care, perineal care (female and male), mouth care (brushing teeth or dentures), providing resident privacy, range of motion (upper or lower extremity), transfers, using gait belt, using mechanic lifts
Disaster planning and procedures - active shooter, elopement, fire, flood, power outage, tornado
Infection control- hand hygiene, isolation, standard universal precautions including use of personal protective equipment, precautions, environmental cleaning
Medication administration - injectable, oral, subcutaneous, topical
Measurements: blood pressure, orthostatic blood pressure, body temperature, urinary output including urinary drainage bags, height and weight, radial and apical pulse, respirations, recording intake and output, urine test for glucose/acetone
Resident assessment and examinations - admission assessment, skin assessment, pressure injury assessment, neurological check, lung sounds, nutritional check, observations of response to treatment, pain assessment
Caring for persons with Alzheimer's or another dementia
Specialized care - catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op and post-op care, trach care/suctioning, ventilator care, tube feedings, wound care/dressings, dialysis care
Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, and implementing nonpharmacological interventions.
II. Training records
The training records were requested on 7/11/23 at 11:23 a.m. The facility was not able to provide competencies for the requested staff as identified in the facility assessment.
III. Interview
The nursing home administrator (NHA) was interviewed on 7/11/23 at 2:15 p.m. She said the facility had planned a skills school for August 2023 to include skill stations for all of the staff. She said the facility did not have current annual competencies for the requested staff. She said it was important to ensure staff could perform skills safely and correctly to provide the best care to the residents.
Jan 2020
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the services provided met professional standards of care fo...
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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 the services provided met professional standards of care for two (#33 and #22) out of 22 sample residents.
Specifically, the facility failed to:
- obtain physician orders prior to placing wheelchair and bed alarms in the Resident #33's wheelchair and bed, and
- obtain physician order prior to placing wheelchair and bed alarms to prevent falls and a wander guard to prevent elopement for resident #22's safety.
Findings include:
I. Facility policy
The undated Restraints policy was provided by the Director of Nursing (DON) on 1/22/2020 at 10:16 a.m., read in part: The resident has the right to be free from any physical restraints imposed for the purpose of discipline or convenience of staff, which are not required by the resident's medical condition .Consultation with appropriate health professionals in the use of less restrictive devices must be documented in the medical record prior to using restraints .Restraints shall be ordered by the attending physician and the order shall include specific reasons for use of the restraints, the specific type of restraint to be used, and the length of time for the restraints.
II. Resident #33
Resident #33, age [AGE], was initially admitted [DATE] and re-admitted on [DATE]. According to the January 2020 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia, pain in the right hip and repeated falls.
The 12/21/19 minimum data set (MDS) assessment, revealed the resident had severe memory impairment with a brief interview for mental status (BIMS) score of 7 out of 15. The resident required varying assistance with activities of daily living due to cognitive changes, weakness, and a history of frequent falls. The resident used bed and chair alarms daily.
The comprehensive care plan, initiated on 7/9/19, identified the resident had poor safety awareness related to leaving the walker next to her bed and ambulating using furniture and walls which resulted in many falls.
A. Record review
A review of the physician orders and progress notes on 1/21/2020 at 11:42 a.m., did not show any physician orders to place a chair and bed alarm on the resident's chair and bed. It was however documented as part of falls prevention interventions in the resident's care plan that the resident will use tab alarm in wheelchair and pad alarm in bed.
B. Staff interview
The DON was interviewed on 1/21/2020 at 10:05 a.m. She said the resident was always restless when awake and unsteady on her feet but tried to walk unassisted which resulted in numerous falls. She said the care team evaluated the resident and decided that a bed and chair alarm would be the best choice for the resident's safety and the facility contacted the resident's family to obtain consent for placing the alarms. The DON said one of the team members was supposed to contact the physician for an order but it was not done. She said physician order would be obtained to re-assess the resident if she was still a candidate for the alarms and another order to place the alarms if found to be in need. The DON said she would educate her staff to follow up on physician orders and to obtain orders prior to initiating and implementation.
The assistant nursing home administrator (ANHA) was interviewed on 1/21/2020 at 10:35 a.m. She said it was not appropriate to take any clinical action in the facility without first obtaining physician orders. She said she would meet with the care team to ensure the right thing was done at all times.
III. Resident #22
Resident #22, age [AGE], was admitted on [DATE] with diagnoses of dementia with behavioral disturbance, anxiety disorder and other specified depressive episodes.
The 12/3/19 minimum data set (MDS) assessment revealed resident's cognitive skills for daily decision making were severely impaired. Delusions and wandering daily were present. She required limited assistance with bed mobility, transfers, eating, toilet use and personal hygiene, and extensive assistance with dressing. Daily medications administered included seven antipsychotic, seven antianxiety and seven antidepressant. Resident was coded to use a wander/elopement alarm daily.
A. Record review
1. Care plan
The comprehensive care plan, dated 9/16/19, revealed:
- Resident #22 exit seeks when she is anxious. Interventions included: place resident in area where frequent observation is possible, provide diversional activities, place monitoring device on resident that sounds alarms when resident leaves building, note which exits resident favors for elopement from facility and alert staff working near those areas.
On 1/21/2020 at approximately 2:00 p.m. the assistant nursing home administrator provided a list of residents with wander guards in the facility. Resident #22 was included on the list.
2. Nursing notes
- On 8/27/19, a nurse documented, Resident not adjusting to new surroundings very well and exhibited numerous exit seeking behaviors tonight. Resident very anxious and ambulating throughout the facility with walker .Resident has wander guard applied, however kept attempting to elope right after dinner and set the alarms off on several occasions.
- On 8/28/19, a nurse documented, Resident set off alarm a few times, stated she wanted to go see family. Resident was able to be redirected.
- On 12/12/19, a nurse documented, Resident in w/c (wheelchair), has pull tab alarm in place to chair and it is also being used in bed, this has been effective to notify staff when she is attempting self transfers.
Further record review revealed the resident's responsible party signed a consent on 12/19/19, tab alarm may be used for safety measures.
The facility failed to obtain physician's orders for the use of tab alarms and a wander guard for Resident #22.
3. Facility follow-up
On 1/21/2020 the facility provided a copy of the resident's physician order for wander guard and tab alarm for Resident #22.
On 1/23/2020 the facility provided a copy of the resident's physician order to discontinue wander guard due to no exit seeking behavior.
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, observations and interviews, the facility failed to ensure one (#22) of six residents reviewed for medic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure one (#22) of six residents reviewed for medication regimen out of 22 sample residents was as free from unnecessary medications as possible.
Specifically, the facility failed to:
-Provide individualized, non-pharmacological approaches to accommodate Resident #22's distress related to the nursing facility admission and preventing exit seeking behavior;
-Timely identify and reassess the need for psychotropic medication therapy after Resident #22's behaviors diminished; and
-Reassess the need for duplicate pharmacological therapy for Resident #22's behaviors.
Finding include:
I. Facility policy and procedure
The undated Psychoactive Drug Usage policy, provided by the assistant nursing home administrator (ANHA) on 1/23/20 at 11:00 a.m., read in part:
Use of psychotropic drugs should be kept to a minimum, used for specific symptoms, and reevaluated regularly. Dosage should be as low as possible and resident observed closely for the onset of extrapyramidal symptoms .Also drugs should be carefully evaluated and monitored monthly or whenever the resident shows sudden changes in behavior.
Procedures included:
Evaluation of appropriateness of resident's medication upon admission is to be documented by the medical consultant. Reevaluation of drug usage shall be accomplished at each care planning conference or whenever the situation warrants it. The pharmacy consultant will complete monthly drug regimen reviews and provide recommendations to the director of nursing services and medical director. Psychotropic medications are those prescribed to manage behavior. These drugs are the option of last resort.
II. Professional reference
Saunders' Nursing Drug Handbook 2020 by Elsevier, read in part:
A. Depakote Sprinkle, Depakote, Depakote ER (anticonvulsant with off-label use as a mood stabilizer for behaviors in dementia).
-Black Box Alert: Life-threatening pancreatitis, hepatotoxicity/hepatic failure.
-Adverse effects: malaise, weakness, lethargy and anorexia.
B. Lexapro (antidepressant used for treatment of generalized anxiety disorder)
-Interaction with Lorazepam (Ativan) may increase CNS depression.
C. Ativan (benzodiazepine, antianxiety and sedative-hypnotic medication with off-label use for rapid tranquilization of agitated patients)
-Side effects included drowsiness and dizziness.
D. Memantine (anti-Alzheimer's agent with off-label use for treatment of mild to moderate vascular dementia)
E. Donepezil (anti-Alzheimer agent with off-label use for treatment of behavioral syndromes in dementia)
III. Resident #22
Resident #22, age [AGE], was admitted on [DATE] with diagnoses of dementia with behavioral disturbance, anxiety disorder and other specified depressive episodes.
The 12/3/19 minimum data set (MDS) assessment revealed the resident's cognitive skills for daily decision making were severely impaired. Delusions and wandering daily were present. She required limited assistance with bed mobility, transfers, eating, toilet use and personal hygiene, and extensive assistance with dressing. Daily medications administered included an antipsychotic, antianxiety, and antidepressant, all administered daily. A wander/elopement alarm was used daily.
A. Resident's family interview
Resident #22's family members and power of attorney (POA) were interviewed on 1/20/19 at 6:00 p.m. They said the resident had declined significantly in both functional and cognitive status since admission to the facility. The POA said the resident had a hard time adjusting in the facility for the first few days after admission due to her lifestyle and environmental changes, and was exit seeking. However, after a couple weeks she was not an elopement risk. The family member said the resident was able to walk long distances with and without her walker, and for the past couple months she was confined to a wheelchair and needed more assistance. The POA said his mother was extremely confused, lost her appetite and became lethargic. He said his plan was to talk to the physician about the medications his mom was taking.
B. Record review
1. Care plan
The comprehensive care plan, dated 9/16/19, revealed:
Resident #22 exhibited signs of depression. Interventions included: monitor and document target behaviors, use one on one visits, praise for her accomplishments, say things that make her feel of value and special, encourage to talk with staff when she is feeling anxious about being in long term care, and social services to monitor mood and behaviors quarterly.
Resident #22 had anxiety related to feeling that people were looking at her and/or talking about her. Her anxiety contributed to her wandering as she would exit seek to get away from people. Interventions included: schedule psychiatric visits as ordered, pharmacy consultant initiation of gradual antipsychotic medication dose reduction, assess for changes in mood status, assist to determine source of anxiety and precipitating events, assess effectiveness of antipsychotic medication therapy, assess effectiveness of antidepressant medication therapy, and assess effectiveness of antianxiety medication therapy.
Resident #22 exhibited exit seeking behavior when she was anxious. Interventions included: place resident in area where frequent observation is possible, provide diversional activities, place monitoring device on resident that sounds alarms when resident leaves building, note which exits resident favors for elopement from facility and alert staff working near those areas.
2. Physician orders
According to the computerized physician orders (CPO) and medication administration records (MARs) for August 2019 through January 2020, the resident received the following medications:
-Ativan 0.5 mg tablet, PRN (as needed) (order date 8/26/19 discontinued 9/13/19)
-Ativan 0.5 mg tablet, give 1/2 (0.25 mg) by mouth daily (order date 9/13/19), behavior monitoring for Ativan, wandering.
-Depakote ER 250 mg, one tablet orally, daily at bedtime (order date 8/23/19, discontinued 12/3/19) for unspecified dementia with behavioral disturbance
-Depakote DR 125 mg Sprinkles, give 2 capsules, orally, twice daily (order date 12/3/19), behavior monitoring for Depakote, irritability.
-Mementine 10 mg tablet, one tablet, by mouth, once a day (order date 8/23/19) for unspecified dementia with behavioral disturbance
-Donepezil 10 mg tablet, one tablet, by mouth, once a day (order date 8/23/19) for unspecified dementia with behavioral disturbance
-Lexapro 5 mg tablet, orally, one time a day (order date 9/13/19), behavior monitoring for Lexapro, crying.
3. Physician note
The 8/22/19 physician note revealed, in part, She does well until mid afternoon and then gets confused and anxious .Depakote ER, 250 mg was started on her last night and she did sleep after that. Mornings are better for her .She has not been combative, but frustrated if her routine is off .It's unclear to me that wandering is patient's normal behavior. There seemed to be an inciting event and then her living space and routine was completely disrupted which is essential in the management of dementia .She is likely not getting much benefit from Namenda and Aricept at this point.
Despite the physician's note above, both medications, Namenda (Mementine) and Donepezil (Aricept), were prescribed and administered since 8/23/19 for unspecified dementia with behavioral disturbance.
The facility failed to reassess the need for duplicate therapy after the resident's behaviors diminished.
4. Nursing notes
On 8/24/19, a nurse documented, Resident .is confused and repeatedly reports she is going to call the police if she doesn't leave here soon. Resident redirected.
On 8/24/19, a nurse documented, anxious, not wanting to be here, was at doors x 3 (three times), redirected back to chair .
On 8/27/19, a nurse documented, Resident not adjusting to new surroundings very well and exhibited numerous exit seeking behaviors tonight. Resident very anxious and ambulating throughout the facility with walker causing distress to several other residents by entering into their rooms without their consent. Resident very confused and Ativan that was administered PRN (as needed) during AM (morning) shift is no longer effective during NOC (night) shift. Resident has wander guard applied, however kept attempting to elope right after dinner and set the alarms off on several occasions.
On 8/28/19, a nurse documented, Resident set off alarm a few times, stated she wanted to go see family. Resident was able to be redirected.
On 8/28/19, a nurse documented, Resident agitated, threatening to leave the facility or call police, unknown what triggered this episode. Not able to redirect. Ativan 0.5 mg administered. Four attempts to exit building. One on one currently.
On 8/28/19, a nurse documented, Resident adjusting much better to new surroundings today than compared with previous days as noted. Resident more social with other residents .watched TV in the common area .Resident currently sleeping comfortably in bed with call light in reach.
Further record review revealed no more notes about elopement or exit seeking behavior, crying or irritability.
On 8/29/19, a nurse documented on the physician communication sheet, (Resident's name) becomes agitated requiring PRN Ativan 0.5 mg. This happens at different times of the day for unknown causes. The 0.5 mg Ativan hits hard the next day. Nursing feels that 0.25 mg daily would benefit her better. Would you consider this?
Although the resident did not exhibit exit seeking behaviors and PRN Ativan was not administered for two weeks in September 2019, the physician prescribed Ativan 0.25 mg daily starting 9/14/19.
5. Medication regimen review (MRR)
On 1/10/2020 the pharmacist documented, We will need a risk vs benefit form for the continuation of Lexapro, Ativan and Depakote.
The pharmacist failed to timely recognize the risk versus benefit was completed by the resident's physician.
C. Resident observations
Resident #22 was observed on 1/20/2020 at 5:20 p.m.in the dining room. She was at the table with visiting family members. She appeared lethargic, and was assisted by staff to consume a few bites of her dinner. She did not respond to any of the questions directed toward her.
Resident #22 was observed on 1/21, 1/22 and 1/23/2020 throughout each day. She was in her wheelchair, assisted by staff from her room to the dining room and to the common area. She was placed in front of the TV in the mornings and left for group activities in the afternoons. She did not actively participate, nor was she encouraged to participate in the activities.
D. Staff interviews
The social service director was interviewed on 1/23/20 at 8:35 a.m. He said the resident was frequently exit seeking for some time after her admission to the facility. He said Resident #22's psychotropic medications were reviewed, however no changes were made even though her behaviors disappeared. He said the resident was not offered any supportive psychological services as those were very limited in the community. He said beside one on one staff supervision and some activities, the resident was not offered non-pharmacological approaches.
The director of nursing (DON) was interviewed on 1/23/20 at 4:50 p.m. She said she had been with the facility for a couple months. She said the facility should provide behavioral health for the resident immediately after her admission to the facility. She said individualized, non-pharmacological interventions, based on the resident's interests and likes, should be implemented. She said the resident should be reassessed when her behaviors changed and the psychotropic medication doses should be reduced or discontinued.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on record review and interviews, the facility failed to ensure required in-service training for nurse aides, no less than 12 hours per year, and included dementia management and resident abuse p...
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Based on record review and interviews, the facility failed to ensure required in-service training for nurse aides, no less than 12 hours per year, and included dementia management and resident abuse prevention training.
Specifically, the facility:
-Failed to ensure five (#1, #2, #3, #4 and #5) out of five certified nurse aides' (CNAs) in-service training records reviewed, completed at least 12 hours of annual training.
-Failed to have a system in place to permanently maintain an in-service training program for nurse aides that was sufficient and effective as determined by the facility assessment and included resident abuse prevention and infection control and prevention.
Findings include:
I. Record review
The Facility Assessment, dated 1/8/2020, was provided by the assistant nursing home administrator (ANHA) on 1/22/2020 at 10:00 a.m. The part addressing staff training/education and competencies, documented: Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; Include dementia management training and resident abuse prevention training; Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff; For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
The Center for Medicare and Medicaid Services (CMS) - 602 Census and Condition form was provided by the director of nursing (DON) on 1/20/2020 at 4:00 p.m. The form revealed the facility had a census of 40 residents; 16 residents had behavioral healthcare needs, 14 residents with dementia and five residents had documented psychiatric diagnoses.
The January 2020 staffing schedule was provided on 1/21/2020 at 9:30 a.m. by the DON. A sample of five CNAs who had been employed longer than 12 months was selected for review of compliance with training requirements.
On 1/22/2020 at 10:00 a.m., the ANHA provided a record titled Nurse Educators Program Continuing Education Tracking Log 2019, for all CNAs working in the facility.
The document revealed abuse and neglect was part of an in-service in May 2019 that included confidentiality and HIPAA (Health Insurance Portability and Accountability Act).
Dementia was part of an in-service in July 2019 that included behaviors, hydration, depression and delirium.
The above document did not specify the length of time for the in-service training.
An x mark documented each CNA's presence in each month in-service training.
The log revealed:
-CNA #2 was not present in February and March 2019,
-CNA #3 was absent from the in-service in March and April 2019, and
-CNA #4 did not participate in the in-service in August 2019.
II. Interviews
CNA #1 was interviewed on 1/23/2020 at 4:10 p.m. She said she did not know how many hours she completed in-service training in 2019.
CNA #2 was interviewed on 1/22/2020 at 10:30 a.m. She said she did not remember how many hours of in-service training she completed in 2019. She said she did not come to some of the training sessions.
CNA #3 was interviewed on 1/23/2020 at 4:30 p.m. She said she did not keep track of the in-service training. She said she missed a couple of the monthly training sessions in the facility.
The ANHA was interviewed on 1/22/2020 at 2:00 p.m. She said the facility did not have an appropriate system in place to keep track of staff participation in in-services provided during monthly meetings. She said the current tracking system needed to be revised to accurately monitor, track and ensure all CNAs receive the required 12 hours in-service training. She said the facility's current training program and method of tracking staff training compliance needed to be revised.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s). Review inspection reports carefully.
- • 29 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $14,768 in fines. Above average for Colorado. Some compliance problems on record.
- • Grade F (13/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is River Valley Rehabilitation And Healthcare Center's CMS Rating?
CMS assigns RIVER VALLEY REHABILITATION AND HEALTHCARE CENTER an overall rating of 1 out of 5 stars, which is considered much 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 River Valley Rehabilitation And Healthcare Center Staffed?
CMS rates RIVER VALLEY REHABILITATION AND HEALTHCARE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 57%, which is 11 percentage points above the Colorado average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at River Valley Rehabilitation And Healthcare Center?
State health inspectors documented 29 deficiencies at RIVER VALLEY REHABILITATION AND HEALTHCARE CENTER during 2020 to 2025. These included: 1 that caused actual resident harm and 28 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates River Valley Rehabilitation And Healthcare Center?
RIVER VALLEY REHABILITATION AND HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CENTENNIAL HEALTHCARE, a chain that manages multiple nursing homes. With 60 certified beds and approximately 50 residents (about 83% occupancy), it is a smaller facility located in DEL NORTE, Colorado.
How Does River Valley Rehabilitation And Healthcare Center Compare to Other Colorado Nursing Homes?
Compared to the 100 nursing homes in Colorado, RIVER VALLEY REHABILITATION AND HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (57%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting River Valley Rehabilitation And Healthcare Center?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is River Valley Rehabilitation And Healthcare Center Safe?
Based on CMS inspection data, RIVER VALLEY REHABILITATION AND HEALTHCARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 1-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 River Valley Rehabilitation And Healthcare Center Stick Around?
Staff turnover at RIVER VALLEY REHABILITATION AND HEALTHCARE CENTER is high. At 57%, the facility is 11 percentage points above the Colorado average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was River Valley Rehabilitation And Healthcare Center Ever Fined?
RIVER VALLEY REHABILITATION AND HEALTHCARE CENTER has been fined $14,768 across 1 penalty action. This is below the Colorado average of $33,227. 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 River Valley Rehabilitation And Healthcare Center on Any Federal Watch List?
RIVER VALLEY REHABILITATION AND HEALTHCARE 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.