What is WILLOW TREE CARE CENTER's CMS rating?

WILLOW TREE CARE CENTER has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does WILLOW TREE CARE CENTER have any serious inspection findings?

Yes, WILLOW TREE CARE CENTER has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 43 total deficiencies from recent inspections.

What are the staffing levels at WILLOW TREE CARE CENTER?

WILLOW TREE CARE CENTER has a three-star staffing rating from CMS with 0.88 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is WILLOW TREE CARE CENTER located?

WILLOW TREE CARE CENTER is located in DELTA, CO. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does WILLOW TREE CARE CENTER have?

WILLOW TREE CARE CENTER has 80 certified beds.

Who owns WILLOW TREE CARE CENTER?

WILLOW TREE CARE CENTER is a for profit - corporation facility and is part of the STELLAR SENIOR LIVING chain.

Is WILLOW TREE CARE CENTER safe?

WILLOW TREE CARE CENTER has documented safety concerns including a substantiated abuse finding on record, 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Do nurses at WILLOW TREE CARE CENTER stick around?

WILLOW TREE CARE CENTER has high staff turnover at 60%. High turnover can mean less continuity of care as staff change frequently.

Was WILLOW TREE CARE CENTER ever fined?

No, WILLOW TREE CARE CENTER has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is WILLOW TREE CARE CENTER on any federal watch list?

No, WILLOW TREE CARE CENTER is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at WILLOW TREE CARE CENTER?

Medicare inspectors have found 43 deficiencies at WILLOW TREE CARE CENTER: 1 critical, 2 serious, 40 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting WILLOW TREE CARE CENTER?

Families visiting WILLOW TREE CARE CENTER should ask about staff retention and training programs, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does WILLOW TREE CARE CENTER compare to other nursing homes?

WILLOW TREE CARE CENTER has a 1-star overall rating, which is below average compared to other nursing homes in CO. Families should carefully review inspection findings and consider alternatives.

WILLOW TREE CARE CENTER

Name: WILLOW TREE CARE CENTER
Address: 2050 S MAIN ST, DELTA, CO, 81416, US
Telephone: (970) 874-9773
Rating: 1.0

2050 S MAIN ST, DELTA, CO 81416 · (970) 874-9773

For profit - Corporation 80 Beds STELLAR SENIOR LIVING Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

0/100

#207 of 208 in CO

Share this report:

WILLOW TREE CARE CENTER nursing home in DELTA, CO - Photo 1 of 4

WILLOW TREE CARE CENTER nursing home in DELTA, CO - Photo 2 of 4

Photo by Joshua Bowsher

View 360° on Google Maps

Last Inspection: January 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Willow Tree Care Center has received a Trust Grade of F, indicating poor quality and significant concerns about care. They rank #207 out of 208 nursing homes in Colorado, placing them in the bottom half of facilities statewide and #3 out of 3 in Delta County, meaning only one local option is better. While the facility is improving overall, with issues dropping from 11 in 2024 to 4 in 2025, there are still serious concerns, including a critical incident during a fire evacuation that caused fear and chaos among residents. Staffing is average with a 3 out of 5 rating, but the high turnover rate of 60% is concerning compared to the state average of 49%. Although there have been no fines, which is a positive note, some specific incidents included inadequate catheter care leading to infections and a resident not receiving necessary assistance during meals, highlighting both strengths and weaknesses in care.

Trust Score: F
In Colorado: #207/208
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Colorado facilities.
Skilled Nurses: Each resident gets 52 minutes of Registered Nurse (RN) attention daily — more than average for Colorado. RNs are trained to catch health problems early.
Violations: 43 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 11 issues

2025: 4 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: 60%

13pts above Colorado avg (46%)

Frequent staff changes - ask about care continuity

Chain: STELLAR SENIOR LIVING

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (60%)

12 points above Colorado average of 48%

The Ugly 43 deficiencies on record

1 life-threatening 2 actual harm

Jul 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for one (#4) of seven residents out of 10 sample residents.Specifically, the facility failed to thoroughly investigate two allegations of physical abuse by Resident #4. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation-Investigating and Reporting policy, revised September 2022, was provided by the director of nursing (DON) on 7/23/25 at 5:12 p.m. The policy read in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. All allegations are thoroughly investigated. The administrator initiates investigations.Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. The individual conducting the investigation as a minimum: reviews the documentation and evidence; reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; observes the alleged victim, including his or her interactions with staff and other residents; interviews the person(s) reporting the incident; interviews any witnesses to the incident; interviews the resident (as medically appropriate) or the resident's representative; interviews the resident's attending physician as needed to determine the resident's condition; interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interviews the resident's roommate, family members, and visitors; interviews other residents to whom the accused employee provides care or services; reviews all events leading up to the alleged incident; and documents the investigation completely and thoroughly.II. Resident #4 1. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician's orders (CPO), diagnoses included anxiety, restlessness and agitation and dementia with other behavioral disturbances.The 5/20/25 minimum data set (MDS) assessment documented Resident #4 had severe cognitive impairments with short-term and long-term memory deficits and had communication deficits per staff assessment. Resident #4's speech was rarely or never understood by others and he had severely impaired vision. The assessment documented Resident #4 was dependent on staff for bathing, dressing, eating and toileting.The assessment indicated the resident exhibited verbal behaviors (yelling, cursing, or threats) and physical behaviors (hitting, kicking, pushing, or grabbing) towards others. The assessment indicated the resident had other behavioral symptoms not directed toward others of disruptive sounds or screaming not directed at others. 2. Record reviewThe progress noted, dated 6/6/25 at 4:50 p.m., documented Resident #4 reached out and firmly grabbed and held three residents within an hour. The other unidentified residents tried to get him to let go and each time Resident #4's hand had to be pried off of the other resident by staff. The action resulted in return aggression from one of the unidentified residents. The note documented no injuries were sustained.The progress note, dated 6/20/25 at 10:25 a.m., documented Resident #4 walked up behind an unidentified resident in their wheelchair, grabbed the resident by the shoulders and squeezed them. Licensed practical nurse (LPN) #1 documented the unidentified resident was irritated by this behavior.A request was made on 7/23/25 for an investigation into the abuse allegations in the resident's electronic medical record (EMR). -The facility was unable to provide documentation to indicate an investigation was conducted related to the 6/6/25 and the 6/20/25 progress notes regarding Resident #4's physically aggressive behaviors. V. Staff interviewsLPN # 1 was interviewed on 7/23/25 at 3:15 p.m. LPN #1 said Resident #4 used to ambulate more often and used to walk up to people and grab them. LPN #1 said she remembered that Resident #4 grabbed other residents on both 6/6/25 and 6/20/25. She said she did not remember which residents he grabbed and she did not remember which residents became upset due to Resident #4's behavior. LPN #1 said she did not recall speaking with the DON about either altercation. LPN #1 said Resident #4 frequently grabbed out at people near him and the behavior did not appear targeted to anyone. She said residents who wandered should be directed away from Resident #4 to prevent them from being grabbed.The nursing home administrator (NHA) was interviewed on 7/23/25 at 5:12 p.m. The NHA said he recently began as the abuse coordinator in July 2025. He said anytime a resident made an allegation of hitting, kicking, slapping, or grabbing residents without consent it should be investigated. He said physical abuse could have occurred any time a resident expressed they did not feel safe and staff should report all potential allegations to the DON within two hours of the incident. The NHA said the DON also reviewed documentation and if she noted anything suspicious, she contacted the NHA to investigate. The NHA said he was not aware of the 6/6/25 or the 6/20/25 progress notes describing resident-to-resident altercations with Resident #4 because they occurred prior to when he began as the abuse coordinator. The DON was interviewed on 7/23/25 at 5:41 p.m. The DON said she had not seen either progress note describing Resident #4's resident-to-resident altercations until the time of the interview. The DON said she thought Resident #4 was no longer grabbing at people because he had become mostly wheelchair-bound due to his disease progression. The DON said after reading the progress notes, she would have investigated the allegations described if she had known about them earlier. The DON said now that she was aware of the allegations of Resident #4's continued grabbing of other residents, she planned to discuss with the interdisciplinary team to prevent Resident #4 from grabbing other wandering residents.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#4 and #6) of seven residents reviewed out of 10 sample residents.Specifically, the facility failed to:-Effectively implement person-centered approaches for dementia care to prevent resident-to-resident altercations for Resident #4; and, -Effectively implement person-centered approaches for dementia care to prevent verbal and physical aggressive behavior as well as wandering/elopement behavior for Resident #6.Findings include: I. Facility policy and procedureThe Dementia Clinical Protocol policy and procedure, revised November 2018, was provided by the director of nursing (DON) on 7/23/25 at 5:12 p.m. The policy read in pertinent part, For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life.The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools). Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT.The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician.The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors.II. ObservationsDuring a continuous observation of the secured unit on 7/22/25, beginning at 3:43 p.m. and ending at 5:19 p.m. the following was observed:At 4:40 p.m. Resident #4 returned to the secured unit after visiting with his spouse. At that time, Resident #4 began to bang his hands on the table. Certified nurse assistant (CNA) #2 asked Resident #4 if he was hungry and assisted Resident #4 with putting on a clothing protector before dinner. At 4:44 p.m. Resident #4 resumed banging his hands on the table. CNA #2 attempted to redirect Resident #4 again, this time with a sensory fidget blanket. Resident #4 called out, but could not be understood by others. At 4:50 p.m. Resident #4 grabbed Resident #8 by the left arm and activities assistant (AS) #1 separated the two residents. After completing the assessment of the left arm of Resident #8, licensed practical nurse (LPN) #2 asked Resident #4 about his needs including pain, hunger, thirst and toileting. Resident #4 responded but could not be understood due to his impaired speech. At 5:02 p.m. Resident #4 grabbed Resident #6. Facility staff separated the two residents again and no injuries were present.At 5:09 p.m. Resident #6 told LPN #2 that he wanted to leave. LPN #2 attempted to redirect Resident #6 by telling him he could not go anywhere without eating dinner. Resident #6 remained upset and walked down the hallway. LPN #2 attempted to walk and talk with Resident #6 until Resident #6 stopped walking and stood by the entrance doors to the unit. At 5:19 p.m. an unidentified staff member walked through the entrance doors to the unit. Resident #6 attempted to push past the staff member and leave the unit.III. Resident #4A. Resident statusResident #4, age greater than 65, was admitted [DATE]. According to the July 2025 computerized physician's orders (CPO), diagnoses included anxiety, restlessness and agitation and dementia with other behavioral disturbances.The 5/20/25 minimum data set (MDS) assessment documented Resident #4 had severe cognitive impairments with short-term and long-term memory deficit and had communication deficits per staff assessment. Resident #4's speech was rarely or never understood by others and he had severely impaired vision. The assessment indicated the resident exhibited verbal behaviors (yelling, cursing, or threats) and physical behaviors (hitting, kicking, pushing, or grabbing) towards others. The assessment indicated the resident had other behavioral symptoms not directed toward others of disruptive sounds or screaming not directed at others.The assessment documented Resident #4 was dependent on staff for bathing, dressing, eating, and toileting.B. Record reviewResident #4's care plan, initiated on 12/2/24 and last revised on 6/22/25, indicated Resident #4 displayed behaviors of tapping his legs and reaching out to hold the staff or resident's arm for comfort if he was anxious. The care plan also documented Resident #4 was at risk for being the victim of resident-to-resident altercations due to his impaired speech and inability to recognize the personal space of other people. Pertinent The interventions included documented in the care plan was to speaking softly and gently to Resident #4 in order to redirect Resident #4 to more desirable activities or location. -Review of the resident's care plan did not include person-centered interventions to prevent Resident #4 from grabbing other residents multiple times (5/8/25 and 7/22/25). Cross reference F600: failure to protect residents from physical abuse. The July 2025 treatment administration record (TAR) (7/1/25 to 7/21/205) revealed the resident was on documented behavior monitoring for anxiety medication. The behaviors that were tracked included grabbing others, banging on walls or doors with his fist, and hitting or kicking during care. The TAR documented Resident #4 had these behaviors seven times. from 7/1/25 through 7/21/25-However, review of the resident's electronic medical record (EMR) did not include documentation indicating person-centered interventions were implemented when the resident displayed behaviors.The CNA behavior tracking task for Resident #4 (from 6/24/25 through 7/22/25), documented Resident #4 had the behavior of grabbing at others 17 times.C. Resident #4's representatives interviewResident #4's representative was interviewed on 7/23/25 at 11:03 a.m. She said when the facility first opened the memory care unit, it did not appear to her that the facility was adequately prepared for dementia residents. She said Resident #4 frequently grabbed at other people and did not understand how hard he was squeezing. She said his behavior did not seem aggressive or directed toward anyone, but related to his dementia and impaired vision and speech. 3. Resident #6A. Resident statusResident #6, age less than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included, traumatic brain injury, history of alcohol dependence with alcohol-induced persisting dementia, insomnia and epilepsy (a seizure disorder) .The 7/17/25 MDS assessment was not complete as Resident #6 had seizure activity requiring hospitalization 7/8/25 and returning to the facility 7/17/25. The nursing admission note, dated 7/19/25, documented Resident #6 was confused with short-term memory loss. The assessment also Resident #6 wandered frequently, was a high risk for elopement and was independent with most activities of daily living, but occasionally incontinent of bowel and bladder. The facility restorative nursing evaluation, dated 7/17/25, documented Resident #6 was able to ambulate independently and perform most activities of daily living independently. B. Record reviewResident #6's baseline care plan, initiated on 7/2/25, indicated Resident #6 displayed behaviors of wandering and elopement attempts with impaired safety awareness. Pertinent interventions included distracting the resident with pleasant activities including structured activities, food, conversation, television, or books, The July 2025 treatment administration record (TAR) documented behavior monitoring for antipsychotic medication. This excluded dates 7/10/25 through 7/17/25 due to a hospitalization. The behavior monitoring documented in the TAR included exit seeking, removing windows, physical aggression, and attempting to break into the nurses station to take items or food. The behavior tracking in the TAR documented Resident #6 with multiple listed behaviors each shift from 7/5/25 through 7/9/25 and on 7/18/25, 7/19/25, 7/21/25 and 7/23/25. The behavior tracking documentation for 7/22/25 (date of the observed elopement attempt) was incomplete.The CNA behavior tracking task for Resident #6 (7/2/25 to 7/9/25 and 7/18/25 to 7/22/25) documented Resident #6 was wandering seven times, yelling four times, grabbing or pushing others 10 times. -However, review of the resident's EMR did not include documentation indicating person-centered interventions were implemented when the resident displayed behaviors.IV. Staff interviewsAS #2 was interviewed on 7/23/25 at 2:06 p.m. AS #2 said Resident #4 frequently grabbed at people around him. She said she did one-to-one activities with Resident #4 because he could not participate in many group activities. AS #2 said she turned Resident #4's wheelchair to face everyone so he felt included even if he was not able to participate. AS #2 said she remembered the globe mirror (a mirror placed on the ceiling that allowed staff to look on the other side of the door) was installed while Resident #6 was in the hospital. She said she remembered there was communication sent to staff that they should contact the memory care unit staff via radio and to check the mirror to make sure the door was clear prior to entering the unit. LPN #1 was interviewed on 7/23/25 at 3:15 p.m. LPN #1 said the globe mirror near the entrance to the unit was installed around the time Resident #6 returned from the hospital. LPN #1 said she was not sure if there was official communication with staff about checking the mirror prior to entering the unit, but she did remember staff were supposed to call on the radio prior to entering the unit. She said not all staff members called but she felt safer doing so because she was not always able to tell if Resident #6 was in the corner near the door by only checking the mirror. CNA #3 was interviewed on 7/23/25 at 4:07 p.m. CNA #4 said she remembered doing computer training for dementia care and attending in person training but could not remember when. CNA #3 said she tried to keep the residents who wander away from Resident #4 to prevent Resident #4 from grabbing them. She said she had not worked much with Resident #6 since he returned from the hospital but she knew they installed a globe mirror near the entrance to the memory care unit so staff could see the other side of the door before opening it. She said she was not aware staff were supposed to call ahead on the radio prior to entering to make sure the door was clear and she said most staff did not. Registered nurse (RN) #1 was interviewed on 7/23/25 at 2:13 p.m. RN #1 said she recently started at the MDS coordinator for the facility, but was working as the unit nurse for the memory care unit on 7/23/25. She said she remembered the globe mirror was discussed in a safety meeting recently but did not remember if there was education or communication sent to all staff to check the mirror prior to entering the unit. RN #1 said she was not sure if staff were supposed to call on the radio prior to entering the unit since she did not regularly work on the unit, but most of the staff had not so far this shift. She said all forms of aggressive behavior needed to be documented to accurately manage residents behavior and make changes to the care plan with the goal of avoiding abuse or injuries. The DON was interviewed on 7/23/25 at 5:41 p.m. The DON said the staff were supposed to communicate with unit staff via radio to make sure the door was clear prior to entering the unit. The DON said she was not aware Resident #4 continued to grab people now that he was mostly confined to a wheelchair and she was not aware how frequently Resident #6 was yelling or physically aggressive toward others. The DON said she planned to discuss new interventions to manage his behavior in the next interdisciplinary team meeting on 7/24/25. The DON said regarding Resident #6, she was working with social worker and unit manager directly to complete Resident #6's care plan since the process was disrupted due to his hospitalization. The DON said many of Resident #6's behavior prior to his hospitalization was related to improper medication management and lack of communication from the previous facility about changes made to his medication prior to admission. The DON said she was not aware of the CNA documentation of Resident #6's aggressive behavior and planned to make corrections to his care plan.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure four (#3, #4, #7 and #8) of eight residents out of 10 sample residents were free from abuse.Specifically, the facility failed to:-Prevent physical abuse between Resident #3 and Resident #4;- Protect Resident #7 from physical abuse by Resident #9; and,- Protect Resident #8 from physical abuse by Resident #4. Findings include: I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention policy, last revised April 2021, was provided by the director of nursing (DON) on 7/23/25 at 5:12 p.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: facility staff; other residents; develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents; and, ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates.II. Incident of physical abuse between Resident #4 and Resident #3 on 5/8/25A. Facility investigationThe facility investigation was provided by the nursing home administrator (NHA) on 7/23/25 at 9:28 a.m. The investigation documented on 5/8/25 at 4:05 p.m. Resident #3 leaned over Resident #4's wheelchair, held the arms of the wheelchair and shook it. Resident #4 grabbed Resident #3's forearm and caused a small abrasion. The event was witnessed by staff and the two residents were separated immediately. Resident #3 was assessed by licensed practical nurse (LPN) #1 and was found to have a small open area on her forearm with a small amount of bleeding requiring a bandage. The investigation documented both residents had severe cognitive impairments and could not recall the incident. The investigation documented increased supervision of residents to keep residents safe since Resident #3 wandered around the unit. The facility investigation indicated the facility substantiated that abuse occurred. B. Resident #3 (assailant and victim)1. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included generalized anxiety and disorder dementia and unspecified severity with other behavioral disturbances.The 5/16/25 minimum data set (MDS) assessment identified Resident #3 had severe cognitive impairments with short-term and long-term memory deficits, per staff assessment. The resident had behaviors of yelling, refusal of care, grabbing and pushing. She required assistance with dressing, bathing and incontinence care. The MDS assessment indicated the resident wandered frequently and had other behavioral symptoms not directed toward others, including throwing or smearing food or bodily waste.2. Record review-Review of Resident #3's electronic medical record (EMR) did not reveal documentation regarding the physical abuse incident on 5/8/25.C. Resident #4 (assailant and victim) 1. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included anxiety, restlessness and agitation and dementia with other behavioral disturbances.The 5/20/25 MDS assessment documented Resident #4 had severe cognitive impairments with short-term and long-term memory deficits and had communication deficits, per staff assessment. Resident #4's speech was rarely or never understood by others and he had severely impaired vision. Resident #4 was dependent on staff for bathing, dressing, eating and toileting. The MDS assessment indicated the resident exhibited verbal behaviors (yelling, cursing, or threats) and physical behaviors (hitting, kicking, pushing, or grabbing) towards others. The resident had other behavioral symptoms not directed toward others of disruptive sounds or screaming not directed at others.2. Resident #4's representative interviewResident #4's representative was interviewed on 7/23/25 at 11:03 a.m. The representative said Resident #4 frequently grabbed at other people and did not understand how hard he was squeezing. She said she had observed the behavior and was informed one time he scratched another resident. She said she did not think the behavior was aggressive, but instead it was related to his dementia, anxiety and impaired vision. 3. Record reviewResident #4's behavior care plan, initiated 12/2/24 and revised 6/22/25, indicated Resident #4 had behaviors that included tapping his legs and reaching out to hold the staff or resident's arm for comfort if he was anxious. The care plan documented the resident had aggressive behaviors that included exit seeking, pacing and grabbing others. Pertinent interventions included identifying patterns of wandering, providing structured activities and providing visits with the resident's spouse. -Review of Resident #4's EMR did not reveal documentation regarding the physical abuse incident on 5/8/25.Review of the certified nurse aide (CNA) behavior tracking task for Resident #4 from 6/24/25 through 7/22/25, revealed it was documented that Resident #4 displayed the behavior of grabbing at others 17 times.III. Incident of physical abuse by Resident #9 towards Resident #7 on 7/7/25A. Facility investigationThe 7/7/25 facility investigation was provided by the NHA on 7/23/25 at 9:28 a.m. The investigation documented on 7/7/25 at 8:15 p.m. Resident #6 displayed agitated and exit seeking behaviors. CNA #5 and LPN #4 were called as additional staff from other halls due to Resident #6's exit seeking behavior as Resident #6 pulled the fire alarm twice that evening. Resident #9 was awakened by the fire alarms and ambulated out of his room and down to the common area. CNA #1 was assisting Resident #9 back to his room and Resident #7 stood in the hallway observing the commotion caused by Resident #6's behavior. While CNA #1 and Resident #9 walked back to Resident #9's room, Resident #6 ran past them attempting to leave the secure unit. The investigation documented the behavior of Resident #6 startled Resident #9 who then struck Resident #7 in the arm. LPN #6 assessed Resident #7 and did not find any injuries. Resident #9 and Resident #7 were interviewed, but did not remember the event. The investigation documented the changes made to prevent a recurrence were to keep residents separate to reduce stimuli if Resident #6 continued to display exit seeking behavior. The facility investigation indicated the facility substantiated the abuse occurred.B. Resident #7 (victim)1. Resident statusResident #7, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included dementia, depression and anxiety. The 6/18/25 MDS assessment documented Resident #7 had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. Resident #7 was dependent on staff for dressing, bathing and hygiene. 2. Record reviewResident #7's behavior care plan, initiated 11/29/23 and revised 6/19/25, indicated Resident #7 had behaviors related to confusion and was at risk for resident-to-resident altercations. Interventions included if Resident #7 was ever triggered by something that might make her appear fearful, staff were to use a calm soothing voice tone with strong reassuring words that she was safe and protected. The care plan interventions documented when Resident #7 appeared or stated she was confused, staff were to provide answers to her questions and guidance to a stable setting.-Review of Resident #7's EMR did not include documentation regarding the incident on 7/7/25.C. Resident #9 (assailant)1. Resident statusResident #9, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included dementia, depression and history of cerebral infarction (stroke). The 5/21/25 MDS assessment documented Resident #9 had severe cognitive impairments with short-term and long-term memory deficits per staff assessment. Resident #9 was dependent on staff for bathing, dressing, toileting, and hygiene. Resident #9 required supervision and verbal cues from staff with ambulating and transferring.The MDS assessment indicated Resident #9 had the behavior of wandering four to six days during the assessment look back period.2. Record reviewResident #9's behavior care plan, initiated 12/10/24 and revised 1/6/25, indicated Resident #9 had verbally abusive behavior related to his dementia. Interventions included anticipating needs by asking about food, water, toileting needs and pain and allowing Resident #9 to express his understanding of the situation and feelings toward the situation.-Review of Resident #9's EMR did not include documentation regarding the incident on 7/7/25.IV. Incident of physical abuse by Resident #4 towards Resident #8 on 7/22/25 A. Observations During a continuous observation of the secured unit on 7/22/25, beginning at 3:43 p.m. and ending at 5:19 p.m., the following was observed:At 4:40 p.m. Resident #4 returned to the common area of the unit. Within a few minutes Resident #4 began to hit the table with his hands repeatedly and call out. Resident #4 was unable to communicate his needs to the CNA who asked if he was hungry. Resident #4 was offered a fidget blanket as a distraction at this time.At 4:50 p.m. Resident #8 was wandering in the common area. Resident #8 walked up to Resident #4's wheelchair. Resident #4 grabbed Resident #8 by the left elbow. Resident #8 yelled ow. Activities assistant (AS) #1 stopped her activity in the common area to intervene upon hearing Resident #8. AS #1 separated the two resident and redirected Resident #4. LPN #2 assessed Resident #8's elbow and did not find any injuries at this time. B. Resident #8 (victim)1. Resident statusResident #8, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included vascular dementia with other behavioral disturbances.The 5/5/25 MDS assessment documented Resident #8 had severe cognitive impairments with short-term and long-term memory deficits and communication deficits per staff assessment. Resident #8's speech was rarely or never understood by others and Resident #8 rarely understood the speech of others. Resident #8 required assistance with toileting, hygiene, dressing and footwear and was dependent on others for bathing.The MDS assessment documented Resident #8 had wandered frequently, but did not have aggressive behavior directed toward others.V. Staff interviewsAS #2 was interviewed on 7/23/25 at 2:06 p.m. AS #2 said Resident #4 frequently grabbed at people around him. She said she did one-to-one activities with Resident #4 because he could not participate in many activities. AS #2 said some residents knew Resident #4 would grab at them if they put their hands out near him, but not all residents on the secured unit were able to remember. She said she kept her eyes on the residents that wandered around the unit since they were at risk of getting grabbed by Resident #4. AS #2 said when Resident #4 grabbed a resident, she was usually able to get him to let go by speaking in a low calm voice. She said she would also use the word please as it prompted Resident #4 to let go. CNA #1 was interviewed on 7/23/25 at 3:07 p.m. CNA #1 said she was working on the unit the day Resident #6 was admitted to the facility. She said Resident #6 was agitated upon arrival to the facility and when his behaviors escalated to pulling fire alarms and banging on doors, she called for additional staff assistance on the walkie-talkies used by staff. She said she had to wait for additional staff to arrive and by the time they were on the unit, multiple residents were overstimulated and having behaviors. She said Resident #6's behaviors lead to the altercation between Resident #9 and Resident #7. LPN # 1 was interviewed on 7/23/25 at 3:15 p.m. LPN #1 said Resident #4 used to ambulate more often and used to walk up to people and grab them. LPN #1 said she remembered Resident #4 ambulated up to residents and grabbed them on both 6/6/25 and 6/20/25. LPN #1 said it was very difficult to keep wandering residents away from Resident #4. She said many times there was only one CNA and one nurse on the unit. LPN #1 said some of the residents required two people for cares and it was difficult to to keep residents who wandered, like Resident #8 and Resident #9 away from Resident #4. CNA #4 was interviewed on 7/23/25 at 3:20 p.m. CNA #4 said Resident #4 would grab anything around him including peoples' hands or arms. She said according to the CNA charting, the resident had physical aggression towards staff and would grab at others. CNA #4 said she said had not seen Resident #4 grabbing at other residents but had observed the resident display physical aggression towards staff when there was loud noises. CNA #3 was interviewed on 7/23/25 at 4:07 p.m. CNA #3 said Resident #4 grabbed at multiple people, but it did not appear that he targeted specific residents. CNA #3 said Resident #4 would grab at anyone he could see and was close enough to him. CNA #3 said she often had Resident #4 grab and hold his own hand so Resident #4 did not grab or pinch her while she fed him.The NHA was interviewed on 7/23/25 at 5:12 p.m. The NHA said he recently started as the abuse coordinator in July 2025. He said physical abuse could have occurred any time a resident expressed they did not feel safe and staff should report all potential allegations to the DON within two hours of the incident. The DON was interviewed on 7/23/25 at 5:41 p.m. The DON said the facility staff had reviewed Resident #4's behaviors in interdisciplinary meetings. The DON said she thought Resident #4 was no longer grabbing at people because he had become mostly wheelchair bound due to his disease progression. She said she not aware of the behaviors observed on the unit on 7/22/25 or the other incidents of Resident #4 grabbing others found in the progress notes that were not investigated. Cross-reference F610 for failure to investigate allegations of physical abuse.The DON said now that she knew Resident #4 continued to grab at people while he was in his wheelchair, she planned to discuss new interventions to manage his behavior in the next interdisciplinary team meeting on 7/24/25.

Apr 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#1) of three residents out of three sample residents received treatment and care for optimal skin condition of a pressure wound, in accordance with professional standards. Specifically, the facility failed to: -Develop and implement a care plan for Resident #1's pressure ulcers; and, -Ensure interventions were implemented timely to prevent the development and worsening of a pressure injury for Resident #1. Findings include: I. Professional reference According to the All [NAME] Tissue Viability Nurse Forum, Best Practice Statement on the Prevention and Management of Moisture Lesions, September 2023, retrieved online 4/4/25 from:chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.wwic.[NAME]/uploads/files/documents/Professionals/Clinical%20Partners/AWTVNF/All_Wales-Moisture_Lesions_final_final.pdf Individuals with incontinence may also have problems with mobility and, as a result, be at risk of developing pressure ulcers as well as moisture lesions. Consequently, when inspecting an individual's skin, it may be difficult to tell if the damage to the skin is caused by moisture alone or moisture in combination with pressure. If the skin is subjected to moisture and pressure, then the treatment strategy will have to overcome both of these insults to the skin. Therefore, along with guidance on how to prevent and manage moisture on the skin, pressure relief will be an important part of care for the individual. Repositioning together with the use of pressure-relieving equipment are the main methods of preventing pressure damage caused by extended periods of localized pressure on the skin. The use of repositioning should be considered in all at-risk individuals as a prevention strategy and should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body. The repositioning schedule should take into account the daily activities of the individual, their ability to tolerate pressure when in the seated and lying positions and the support surfaces in use. If a moisture lesion does not respond to interventions to minimize the effects of moisture alone, then the clinician should consider whether pressure is contributing to the damage and introduce repositioning and pressure relief into the individual's care. II. Resident #1 A. Resident status Resident #1, age greater than age [AGE], was admitted on [DATE] and discharged on 2/15/25. According to the February 2025 computerized physician orders (CPO), diagnoses included acute kidney failure, malignant neoplasm of the prostate (prostate cancer), cognitive communication deficit, weakness and need for personal care. The 2/25/25 minimum data set (MDS) assessment indicated Resident #1 had severe cognitive impairments with a staff assessment for mental status. The resident required staff assistance for most of his activities of daily living (ADLs) and used a wheelchair for mobility. B. Record review The pressure ulcer care plan, initiated 11/2/24, documented Resident #1 had the potential for a pressure ulcer/injury to his coccyx or potential for pressure ulcer development related to dehydration, and immobility. The care directed staff to document the resident's treatment weekly. According to the care plan, the documentation should include the measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. -The pressure ulcer care plan did not identify interventions to prevent the development of a pressure ulcer to his coccyx were identified on his care plan. The skin impairment care plan, initiated 12/20/24, documented Resident #1 had the potential impairment to his skin integrity due to his fragile skin. The care plan indicated the resident had a stage 2 and stage 3 pressure ulcer/injury. According to the care plan, the resident was anticipated to have a decline in his skin condition and would have interventions to help maintain his comfort. The following interventions were put in place after Resident #1 developed pressure injuries: specialty bed air mattress, initiated 12/20/24; pressure relieving bed mattress, initiated 12/27/24; avoid scratching and keep his hands and body parts away from excessive moisture and keep his fingernails short, initiated 12/27/24; and, encourage good nutrition and hydration in order to promote healthier skin, initiated 12/27/24. The 10/22/24 admission data collection assessment did not identify Resident #1 had any issues or indications of a pressure injury on his admission to the facility. According to the assessment, the resident had no history of skin issues. The October 2024 CPO revealed a physician's order that directed staff to treat Resident #1's coccyx with soap and water and cover it with bordered foam sacral dressing, ordered on 10/29/24 and discontinued on 12/15/24. -The EMR did identify documentation of a coccyx wound found on 10/29/24 requiring treatment or if coccyx was treated as directed by the physician. Review of the November 2024 and December 2024 medication administration record (MAR) and treatment administration record (TAR) did not identify Resident #1's coccyx was cleansed with soap and water and covered with bordered foam sacral dressing per the physician's order. The 10/29/24 Braden Scale assessment (a tool for predicting pressure ulcer risk) identified Resident #1 was at moderate risk for developing pressure sores. -Review of the resident's electronic medical record (EMR) did not reveal the reason the nurse requested treatment on 10/28/24 (see interviews below). The 10/29/24 skilled charting assessment documented Resident #1's skin was pale, warm and dry. -The skilled charting assessment did not identify concerns with the resident's skin. The 10/29/24 skin and wound total body assessment documented the resident had no new wounds. The 11/10/24 nursing progress note identified Resident #1's resident representative was told the resident had a wound on his coccyx. According to the note, the resident's coccyx would be looked at during wound care on the following morning (11/11/24). -Review of Resident #1's electronic medical record (EMR) did not reveal the resident was assessed by the wound care team on 11/11/24. A 11/11/24 general note documented Resident #1 did not have an open area or a wound but had a dressing over his sacral area to prevent skin breakdown due to his bony prominence. According to the note, the resident's representative felt the resident was not being assisted out of bed. The note documented the resident was given a choice to get out of bed and he wanted to eat in his room. The note documented the staff could encourage Resident #1 to spend time out of bed. -Review of the pressure ulcer risk care plan, dated 11/2/24, did not identify staff were directed to encourage the resident to spend time out of bed or interventions for the resident to offload pressure off his bony prominences. The 10/29/24 skin and wound total body assessment documented the resident had no new wounds. Review of Resident #1's skin and wound total body assessment on 11/5/24, 11/12/24, 11/19/24 and 11/26/24 did not document the resident had new wounds. The 11/28/24 progress note documented a certified nursing assistant (CNA) notified the nurse of an open area to Resident #1's sacrum when she was changing his brief. The open area measured 1.9 centimeters (cm) length by 1.9 cm width. According to the note, the area was cleansed and hydrocolloid dressing (moist dressing designed to absorb fluids) was applied to the area. The physician was notified. Review of the November 2024 and December 2024 CPO did not reveal a physician's order for hydrocolloid dressing or how often the open area should be cleansed and covered with hydrocolloid dressing. Review of the November 2024 and December 2024 MAR and TAR between 11/28/24 and 12/15/24, did not identify Resident #1's open area to his sacrum was cleansed and treated hydrocolloid dressing with coccyx was cleansed with soap and water and covered with bordered foam sacral dressing. The 11/28/24 situation background assessment and recommendation (SBAR) summary for providers note identified Resident #1 had a change of condition related to a skin wound or ulcer. According to the note, the resident did not like to lay on his side so a pillow was placed behind him to help him offload pressure from his back. -The intervention to place a pillow behind Resident #1 to help him offload pressure was not included on the resident's above care plan. The 12/10/24 nursing progress note documented Resident #1 had two more open areas to his buttocks. According to note, the open areas were cleansed and re-dressed. The note did not identify the location of the open areas on his buttocks, the condition, the appearance or the causation of the two additional open areas to his buttocks. Review of the resident's EMR did not identify the nurse assessed and documented measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate on 12/10/24 or shortly after the identification of the new wounds. The 12/13/24 nutrition note documented Resident #1 was not interested in eating but he requested to walk to the dining room because he still felt he had pep. The registered dietitian (RD) increased his oral nutritional supplement to three times a day with meals. The RD recommended Resident #1 be encouraged to get out of bed for repositioning/off-loading due to his stage 2 pressure injury to his coccyx. -The review of the resident's care plan did not direct staff to encourage and assist the resident to get out of bed for repositioning and off-loading. The care plan did not direct staff to assist or encourage the resident to walk to the dining room for meals. The 12/13/24 skin and wound evaluation revealed Resident #1 had a stage 3 pressure ulcer with full thickness skin loss on medial sacrum (on the center of his sacrum bone). The stage 3 injury was identified as a new wound, facility acquired and deteriorating with 100% slough. The pressure injury measured 3.3 cm length by 2.2 cm width with fragile surrounding skin with risk for breakdown. The pressure injury was identified as healable. According to the evaluation, the wound was treated with generic wound cleanser and hydrocolloid foam dressing. The wound documented the resident had pain during the dressing application. The evaluation indicated the use of a low air loss air mattress, educating staff to turn and reposition the resident frequently and to get the resident up out of bed for meals. The evaluation documented the facility was waiting for the arrival of a low air loss air mattress. -The review of the December 2024 TAR revealed the pressure redistribution mattress/low air loss/alternating pressure mattress for prevention and pressure relief, was not in place for use until 12/21/24, seven days after it was identified as intervention to his pressure ulcer. -The evaluation did not identify a second open area to the resident's buttock as identified in the above 12/10/24 nursing note. Review of Resident #1's December 2024 CPO revealed the following physician's orders: Daily wound review on every shift for wound management of Resident #1's sacrum, ordered 12/15/24 and remained an active till his discharge. Daily wound review on every shift for wound management of Resident #1's left gluteus, ordered 12/15/24 and remained an active till his discharge. Left gluteal wound care: Cleanse with wound cleanser; apply 3 by 3 hydrocolloid and cover with bordered foam dressing; change every dressing on Monday, Wednesday and Friday, ordered 12/15/24 and discontinued 12/21/24. Sacral wound care: cleanse wound with wound cleanser; apply 3 by3 hydrocolloid; cover with bordered foam dressing; change every Monday, Wednesday and Friday, ordered 12/16/24 and discontinued 12/21/24. The 12/18/24 electronic medical administration record (EMAR) general note documented Resident #1 received a daily wound review on 12/18/24. The note identified Resident #1 had a wound on his sacrum and on his left gluteus. According to the note, staff should document every shift for his sacrum and left gluteus wound management document the condition of his wound bed, drainage amount, odor, surrounding skin and pain level and dressing situation. The 12/19/24 wound initial note identified Resident #1 had a consultation from a wound care physician (Physician #1) to review two pressure ulcers/injuries. The note documented Resident #1 had an unstageable pressure injury to his sacrococcyx and a stage 3 pressure injury to his left buttock. The wound note revealed the sacrococcyx unstageable pressure injury measured 3.5 cm by length 3.5 cm width by 0.4 cm depth with 100% slough. The stage three pressure injury to the resident's left buttock measured 2.5 cm length by 2.5 cm width x 0.1 cm depth with 100% granulation. According to the note, the treatment recommendations were identified as the following: clean the sacrococcyx with normal Saline (a salt water solution); apply Santyl (ointment to remove dead skin) and gauze; change the dressing daily and as needed if the dressing became dislodged, saturated or soiled. The wound initial note identified the wound care physician directed staff to implement pressure relieving measures and offloading as tolerated; prevent contact of his heels with the bed or other surface and TO consult with the RD to optimize nutrition per facility or dietary protocol to promote wound healing. The wound care note indicated the wound care physician would re-evaluate Resident #1 in one to two weeks. The 12/20/24 interdisciplinary note (IDT) note documented the Resident #1 was placed on weekly wound arounds as of 12/19/24 and was currently getting up for meals. Review of wound treatment notes between 1/2/25 and 2/13/25 identified the wound physician continued to evaluate Resident #1's wound and adjust the treatment plan. On 1/2/25 the unstageable Sacrococcyx pressure was documented as unavoidable. On 1/9/25 the pressure to his left buttock was resolved. III. Staff interviews The director of nursing (DON) and the nursing home administrator (NHA) were interviewed on 4/15/25 at 4:29 p.m. The DON said the facility inspected the resident's skin weekly, applied lotion to the skin after bathing and changing the resident, encouraged food and fluid intake, encouraged them to spend time out of bed and had the RD assess the resident's nutritional needs for pressure injury prevention. The DON said the facility provided specialty cushions depending on the needs of the resident and air mattresses if the resident was at high risk for pressure injuries and or had current pressure injuries. She said the air mattresses were low air low mattresses that helped alternate pressure for residents that were not able or unable to reposition on their own. She said the staff repositioned the residents at least every two hours and that should be included on the resident's care plan. The DON said Resident #1 was identified a risk for pressure injuries and developed pressure injuries while admitted to the facility. Resident #1 was not placed on an alternating pressure air mattress when his risk for pressure injuries was identified because his discharge plan was to receive therapy and return to the community. She said the alternating pressure air mattress was usually reserved for long term residents with an actual pressure injury. The NHA said all residents were provided a pressure redistribution mattress. The DON said the facility did not have a wound care certified nurse. She said she was not sure if Resident #1 was seen by his physician after the resident was identified to have an open area to his sacrum on 11/28/24. She said the resident was seen by a wound care physician on 12/19/24. The DON said she reviewed the resident's EMR and said the physician was notified of the open area on 11/28/24 but she could not find documentation to show the resident's physician saw the wound or was updated on the status of the wound between 11/29/24 and 12/17/24. The nursing home administrator (NHA) and the DON were interviewed together on 4/16/25 at 11:00 a.m. The DON said the nurses were responsible for nursing care provided but she was responsible for the overall wound care of the facility residents. The DON said Resident #1's pressure injuries were facility acquired. The DON said the resident was provided the alternating pressure air mattress in December 2024 because he had an open area, he refused to get out of bed or reposition and had bony prominences. -However, review of the progress notes and care plan did not identify the resident refused to be repositioned. The review of the progress notes only documented the resident refused to get out of bed on 11/11/24 when his representative asked why was not out of bed and on 11/16/24 when he did not want to get out of bed to take a phone call at the nursing station. The DON said she did not know why the nurse on 10/28/24 requested a treatment order for Resident #'s coccyx on 10/28/24. The DON said she was not informed of a concern to his coccyx and an assessment was not completed to identify the resident would need treatment orders. The DON said she did not know why a nurse told the resident's representative on 11/10/24 that Resident #1 had a wound to his coccyx and he would be included in wound rounds. The DON said she thought there may have been some miscommunication to the nurse and the resident was not scheduled to be seen in wound rounds. She said wound rounds would be documented in the resident's medical record. The DON said the resident was not placed on wound rounds after an open area was identified on 11/28/24 because the nurses were doing the wound care. She said she conducted the wound wounds but all nurses were responsible for wound care. She said the wound on his sacrum worsened while he was admitted to the facility. The DON said the open area to the resident sacrum was a pressure injury due to lack of nutritional intake and refusal to get out of bed. She said staff would have repositioned him every two hours but the repositioning would not have been documented. The DON said the care plan should have included repositioning, encouraging him to get out of bed and that he refused. She said the care plan did not direct staff on what to do if the resident refused. She said the care plans needed improvement. The DON said she did not know why a nurse documented the resident had two more open areas on his buttocks or if one of the areas referenced the open area on his sacrum. She said if there were additional open areas then there should have been an assessment, new orders, interventions and tracking. The DON said she observed the resident's sacrum/coccyx on 12/17/24 and identified an open area with slough and determined the resident required mechanical debridement (the physical removal of unhealthy tissue). The DON said Resident #1 was seen by the wound physician through telehealth on 12/19/24 where he found two open areas. The DON and the NHA were interviewed again on 4/16/25 at 1:45 p.m. The DON said when a resident had a change in condition such as a change in the resident's skin, the facility would document the change and monitor the resident for 72 hours on every shift. The DON said a wound care specialist would not be involved in the resident's skin care if the facility nurse felt the management of Resident #1's wound could be handled by staff. The DON said there was no wound care documentation of Resident's sacrum wound and thinks he may have been missed or tracked. The DON said in December 2024 she did not know the resident should have had daily a wound review after a wound was identified. The DON said the nurses did not complete the weekly skin assessments for Resident #1. The DON said she assessed Resident #1 on 12/13/24 and the wound worsened from 1.9 cm by 1.9 cm to 3.3 cm by 2.2 cm with 100% slough. The DON said she continued the same intervention of hydrocolloid until the resident was seen on 12/19/24 with the wound physician. The DON said the facility needed to continue to improve on documentation, communication, showing refusals and interventions and tracking skin concerns. She said the facility needed to increase their education on wound care and she was in the beginning stages of working becoming wound care certified. The NHA said the facility would immediately start educating staff. She said in May 2025, a wound care physician would be able to see the resident's in person and not on telehealth. The NHA was interviewed on 4/16/25 at 2:25 p.m. The NHA said she spoke with the facility's clinical consultant and was directed to start a whole facility review of resident skin and wounds. She said based on the findings, new treatment and interventions would be implemented and the care plans would be updated.

Jan 2024 11 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for one (#11) of three residents reviewed for bathing preferences out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #11 was offered showers twice a week on the resident's scheduled and preferred days; -Ensure Resident #11 had opportunities to refuse showers at the time the shower was offered but still had a shower available to him on his preferred day and scheduled day or shortly after; and, -Ensure Resident #11 could choose between showers and the resident's preference to attend activities of choice without losing a shower opportunity. Findings include: I. Facility policy The Resident Rights policy, undated, was provided by the facility on 1/25/24. According to the policy, residents have the right for self-determination. The Activities of Daily Living (ADLs), Supporting policy, revised March 2018, was provided by the facility on 1/25/24. The policy read in part: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. II. Resident status Resident #11, over the age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), primary osteoarthritis of the right wrist, right shoulder pain, muscle weakness, unsteadiness on his feet, difficulty walking, dementia and a need for assistance with personal care. The 3/17/23 admission minimum data set (MDS) assessment identified Resident #11 required partial to moderate assistance from staff with bathing. According to the 3/17/23 MDS assessment, it was very important for Resident #11 to participate in his favorite activities. The 12/7/23 (MDS) assessment indicated the resident's cognition was intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident did not have behavioral symptoms or exhibit behaviors of rejection of care. III. Resident interview Resident #11 was interviewed on 1/22/24 at 12:09 p.m. He said was supposed to get a shower twice a week and sometimes he did not get a shower for seven to 10 days. Resident #11 was interviewed again on 1/24/24 at 1:22 p.m. The resident said he sometimes would refuse the shower because staff would often offer the shower at the same time as bingo. He said he told staff he would rather go to bingo at that time. He said if staff asked if he wanted a shower or bingo he would always choose bingo. IV. Record review The bathing shower schedule identified Resident #11 preferred two showers a week on Tuesdays and Fridays on the day shift before noon. Resident #11's shower records for October 2023, November 2023, December 2023 and January 2024 were reviewed. The October 2023 shower record was reviewed between 10/11/23 and 10/31/23. The shower record identified Resident #11 received two showers on Friday 10/13/23 and Sunday 10/29/23. The resident refused the shower on Tuesday 10/17/23 and Friday 10/20/23. -The October 2023 shower record did not identify whether the resident was offered a shower again on 10/17/23 or the following day on 10/18/23 after the resident refused the 10/17/23 shower. -The October 2023 shower record did not identify whether the resident was offered a shower again on 10/20/23 or the following day on 10/21/23 after the resident refused the 10/20/23 shower. -The October 2023 shower record did not identify the resident was offered a shower on his preferred shower days of Tuesday 10/24/23 or Friday 10/27/23. -The October 2023 shower record did not identify the resident received two showers the week of 10/22/23 through 10/28/23. -The October 2023 progress notes did not identify Resident #11 refused showers, attempts to offer showers after the resident refused, or why the resident refused the showers in October 2023. The November 2023 shower record identified Resident #11 received showers on: Friday 11/3/23, Friday 11/10/23, Friday 11/17/23, Tuesday 11/21/23 and Tuesday 11/28/23. -The November 2023 shower record did not identify the resident refused showers in November 2023. -The November 2023 shower record did not identify whether the resident was offered his preferred two showers a week or offered consistently on Tuesdays and Fridays. -The resident was not offered a shower on: Tuesday 11/7/23, Tuesday 11/14/23 and Friday 11/21/23. -The November 2023 progress notes did not identify why the resident was not offered showers on 11/7/23, 11/14/23 and 11/21/23. The November 2023 activity calendar identified bingo was offered at 1:30 p.m. on Sundays, at 10:00 a.m. on Wednesdays, and in the evening at 6:00 p.m. on Fridays. -The activity calendar read bingo was offered on Friday evenings. The December 2023 shower record identified Resident #11 received showers on: Friday 12/1/23, Tuesday 12/5/23, Friday 12/8/23, Tuesday 12/12/23, Friday 12/22/23 and Friday 12/26/23. The December 2023 shower record identified Resident #11 refused showers on: Friday 12/15/23, Tuesday 12/19/23 and Friday 12/29/23. -The December 2023 shower record did not identify Resident #11 was offered showers later on the days he refused the showers or the day after he refused the showers. -The December 2023 progress notes did not identify the resident refused his showers in December 2023 or why the resident refused his showers. The December 2023 activity calendar identified bingo was offered on: Friday 12/1/23 at 1:30 p.m. and Friday 12/8/23 at 6:00 p.m. According to the December 2023 activity calendar bingo was moved to 10 a.m. on Friday 12/15/23 and Friday 12/29/23. -Bingo was moved to mid morning on Friday 12/15/23 and 12/29/23 at approximately the same time the resident was scheduled for a shower. The resident refused the shower on 12/15/23 and 12/29/23. The January 2024 shower record between 1/1/24 and 1/24/24 identified Resident #11 received showers on: Tuesday 1/9/24, Tuesday 1/16/24 and Tuesday 1/23/24. The January 2024 shower record identified Resident #11 refused showers on Friday 1/5/24, Friday 1/12/24 and Friday 1/19/24. -The January 2024 shower record did not identify whether the resident was offered a shower on 1/5/24, 1/12/23 or 1/19/23 at a different time of the day or the following day after the resident refused the shower. The January 2024 activity calendar identified bingo was offered consistently at 10:00 a.m. on Friday 1/5/24, Friday 1/12/24 and Friday 1/19/24. -Resident #11 refused his shower on Friday mornings in January 2024 when bingo was scheduled on Friday mornings at 10:00 a.m. -The January 2024 progress notes did not identify the resident refused his showers in January 2024 or why the resident refused his showers. The ADL care plan, initiated 3/10/23 and revised 6/10/23, revealed Resident #11 had an increased risk for actual or potential limitations in his ability to perform his ADLs. According to the care plan staff would assist Resident #11 to maintain his functional status and decrease his risks for functional decline to perform and/or assist with completing his ADLs. The staff would encourage the resident to participate to the fullest extent possible with each interaction. -The care plan did not include the resident's shower preference or whether he had a history of refusing showers or why he refused his showers. The care plan did not identify interventions to encourage the resident to shower or give alternatives when the resident refused his shower. V. Staff interview The director of nursing (DON) and the corporate consultant (CC) were interviewed on 1/25/24 at 4:45 p.m. The CC said the resident's care plan was one way to guide staff on how to take care of a resident. The care plan should include interventions that reflect a resident's preferences and needs. The DON said residents were asked their bathing preferences on admission. The residents had the option to change their bathing preferences during their stay at the facility. The DON said if a resident refused a shower staff should try to offer the shower at different times of the day and, if needed, with different staff. If the resident continued to refuse the shower after the three attempts staff should report the refusal to the nurse. The nurse would document the refusal in the progress notes. The notes should include why the resident refused, such as a conflict with an activity. She said it would be important to know the reason for the refusals so the shower times could be adjusted. The DON said if a resident's shower conflicted with an activity the resident wanted to attend the staff could change the shower time to a time when the resident was available to shower. The DON said she was not aware of why the resident refused some of his showers in December 2023 and January 2024. She said the resident may have reported the reasoning to his certified nurse aide but it was not shared with anyone else.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0573 (Tag F0573)

Could have caused harm · This affected 1 resident

Deficiency Text Not Available

Read full inspector narrative →

Deficiency Text Not Available

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to complete a Level I preadmission screening and resident review (PASARR) for one (#19) of two residents reviewed for PASARR out of 33 sample residents. Specifically, the facility failed to ensure Level I preadmission screening was completed for Resident #19 who had a mental disorder present when admitted to the facility. Findings include: I. Facility policy The PASARR policy was requested on 1/25/24 from the nursing home administrator (NHA) and the NHA said the facility did not have a PASARR policy. II. Resident status Resident #19, over the age of 65, was admitted on [DATE]. According to the January 2024 computerized physician orders, diagnoses included diabetes, multiple sclerosis, cognitive communication disorder, epilepsy and bipolar disorder. The 11/3/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required partial assistance from staff for toileting, hygiene and transfers. She needed substantial assistance for showers and was independent with bed mobility. The resident was non-ambulatory and used a manual wheelchair for mobility. The assessment documented the resident had not been evaluated by Level II PASARR for serious mental illness, the resident had manic depression/bipolar disease at the time of admission to the facility and was prescribed antipsychotic medication. III. Record review -Review of the resident's medical record revealed no documentation a Level I PASARR was completed for the resident. IV. Staff interviews The social services director (SSD) was interviewed on 1/25/24 at 8:45 a.m. She said it was an oversight,and was unaware the Level I PASARR was not completed prior to admission. The SSD indicated the Level I PASARR was not done initially when the resident was admitted to the facility. The SSD said she initiated the Level I PASARR on 1/25/24 at 8:26 a.m. The corporate consultant (CC) was interviewed on 1/25/24 at 4:05 p.m. She said the facility failed to obtain the PASARR Level I. She said it was the SSD responsibility to ensure the screening was completed at admission. She said the SSD would ensure all residents had completed PASSAR screening results in their medical records.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Deficiency Text Not Available

Read full inspector narrative →

Deficiency Text Not Available

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to provide person-centered dementia care and services for two (#21 and #41) of five residents reviewed for dementia care out of 33 sample residents. Specifically, the facility failed to: -Provide dementia care services for Residents #21 and #41 to provide their highest practicable quality of life and care; -Address behaviors, prevent resident-to-resident altercation; and, -Ensure appropriate and non-pharmacological approaches were provided by staff to engage residents with life in the facility. Findings include: I. Facility policy The Dementia Clinical Protocol policy, revised November 2018, was received by the nursing home administrator (NHA) on 1/25/24 at 7:30 p.m. It read in pertinent part, For the individual with confirmed dementia, the facility will identify a resident-centered care plan to maximize the remaining function and quality of life. Direct care staff will support the resident in initiating and completing activities and tasks of daily living to include therapeutic and recreational activities which will be supervised and supported throughout the day as needed. The physician will order appropriate interventions to address significant and psychiatric symptoms. Medications will be targeted to specific symptoms and will be used in the lowest possible doses for the shortest possible time, unless a clinical rationale for longer-term use is documented. II. Resident #21 A. Resident status Resident #21, over the age of 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included unspecified dementia with unspecified severity with behavioral disturbance and anxiety. The 11/21/23 minimum data set (MDS) assessment documented Resident #21 had severe cognitive impairment, was rarely or never understood, and was unable to complete the brief interview for mental status (BIMS). He had delirium symptoms including inattention and disorganized thinking. He had mood symptoms that included little interest or pleasure in doing things, trouble concentrating on things, such as reading the newspaper or watching television. He experienced delusions. He had physical and verbal behavioral symptoms directed toward others and directed towards others and wandering behavior. He was dependent on staff assistance for toileting and hygiene, showering, dressing, oral hygiene, required supervision for bed mobility and transfers, ambulation, and eating. The resident was prescribed antipsychotic, antianxiety and antidepressant medications at the time of the assessment. B. Record review The January 2024 CPO included: -Citalopram, 20 milligram (mg) daily for depression, prescribed 11/16/23; -Risperidone, 1 mg daily for dementia, prescribed 1/12/24; and, -Alprazolam 0.25 mg, daily for anxiety twice daily, prescribed 1/22/24. The 11/10/23 nurse progress note documented the resident was irritable and paced in his room. The 11/13/23 nurse progress note documented the resident was unable to engage in staff led activities. The 11/14/23 nurse progress note documented the resident wandered into other resident rooms, urinated in an inappropriate place, crawled on the floor and removed his clothing as the staff tried to redirected him to his room. The 11/18/23 nurse progress note documented the resident grabbed at a staff member's head and removed her protective face mask. The 11/21/23 nurse progress note documented the resident was physically combative with staff during care. The 11/27/23 nurse progress note documented the resident destroyed property in his room. The 12/2/23 nurse progress note documented the resident turned his room upside down, his food tray and food on floor, the resident tracked food across the room from pacing and the resident was restless and agitated. The 12/10/23 nurse progress note documented the resident was uncooperative with staff for care. The 12/15/23 nurse progress note documented the resident stayed on the floor in his room all night. The 12/17/23 nurse progress note documented the resident slept on the floor in his room. The 12/19/23 nurse progress note documented the resident refused to take his antianxiety medications. The 12/22/23 nurse progress note documented the resident was uncooperative and refused care from staff. The 12/27/23 nurse progress note documented the resident grabbed at staff and refused care. The 12/26/23 nurse progress note documented the resident yelled at staff and refused care. The 1/5/24 nurse progress note documented the resident tore apart his bed frame and call light. The 1/2/24 nurse progress note documented the resident was combative and refused care. The 1/14/24 nurse progress note documented the resident tore the call light mechanism out of the wall in his room. The 1/13/24 nurse progress note documented the resident grabbed at other residents. The 1/12/24 nurse progress note documented the resident refused care and attempted to hit and kick others. The 1/10/24 nurse progress note documented the resident refused personal hygiene care from staff. The 1/15/24 nurse progress note documented the resident refused personal care. The 1/17/24 nurse progress note documented the resident had anxiety, tore the curtains off the bathroom window, took the door off his closet and it was difficult to calm the resident. The 1/18/24 nurse progress note documented the resident was anxious and had an altercation with another resident ( #21). The resident fell to the floor during the altercation (cross-reference F600 for abuse). The 1/19/24 physician progress note documented the physician and wife felt the resident had improved mood and no medication changes were recommended. The 1/20/24 physician progress note documented the resident pulled the call light mechanism off the wall in his room and that he was anxious, touched others and refused care. The 1/21/24 nurse progress note documented the resident was combative, agitated, destructive to property, touched, grabbed and pulled at staff and other residents. The 1/22/24 nurse progress note documented the resident was agitated. The 1/23/24 nurse progress note documented the resident was destructive to the television and dresser in his room, agitated and refused personal care from staff. Review of Resident #21's antipsychotic and antianxiety medications care plan, initiated 11/10/23, included pertinent interventions to administer medications as ordered, monitor/document for side effects and effectiveness, consult with pharmacy and physician, discuss with, monitor/record/report to physician side effects and adverse reactions of psychoactive medications and behavior symptoms not usual to the resident. Review of Resident #21's care plan for his dependence on staff for meeting emotional, intellectual, physical, spiritual and social needs related to dementia with behavioral disturbance, mood disturbance, and anxiety, was initiated on 11/15/23. Pertinent interventions read the resident enjoyed the outdoors and used to hunt, fish and ride four wheelers and he enjoyed classic rock music and staff should escort the resident to musical activities when offered. Review of Resident #21's care plan for impaired cognitive function/dementia or impaired thought processes, was initiated on 11/10/23. Pertinent interventions included administer medications as ordered, monitor/document for side effects and effectiveness and communicate with the resident/family/caregivers regarding resident's capabilities and needs. Review of Resident #21's care plan for behavior, initiated 11/10/23, revealed the resident had an actual and/or potential for alteration in my mood and behavior. The resident's preferences were to approach him gently, staff may have to repeat with yes/no questions. The resident might become agitated and remove/break items in the room. Pertinent interventions included staff to assist the resident/family/caregiver to identify strengths, positive coping skills, and reinforce and identify approaches based on causal and contributing factors for my behaviors. -The record review revealed the resident had agitation, destruction, touching and grabbing others and wandering behavior, however; the comprehensive care plan failed to have personalized interventions to address his behaviors. -After the 1/18/24 altercation the resident was placed on a frequent check (every 10 minutes) program for safety that was not included on the care plan. III. Resident #41 A. Resident status Resident #41, over the age of 65, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included Alzheimer's disease and unspecified dementia with unspecified severity without behavioral disturbance. The 11/10/23 MDS assessment documented the resident had severe cognitive impairment as evidenced by a BIMS with a score of four out of 15. He had delirium indicators continuously present of inattention and disorganized thinking. He needed supervision and setup assistance from staff for personal and toilet hygiene. B. Record review The January 2024 CPO included: -Risperidone 1 mg daily for dementia, prescribed on 1/19/24; -Monitor behavior: agitation with exit seeking, ordered 1/5/24; and, -Wanderguard placement secured, ordered 11/4/23. The 11/14/23 nurse progress note documented the resident was verbally aggressive with staff during assessment and he slept in another room. The 11/10/23 nurse progress note documented the resident was confused and refused care. The 11/26/23 nurse progress note documented the resident yelled at staff and grabbed his medications from the nurse. The 12/16/23 nurse progress note documented the resident wandered into another resident's room, was angry when redirected from staff, scratched the CNA, removed his soiled pajama bottoms and left in the other resident's room. The 12/19/23 nurse progress note documented the resident refused care and yelled at staff. The 12/27/23 nurse progress note documented the resident wandered into the hallway from his room without pants or underwear. The 1/1/24 nurse progress note documented the resident refused his medications. The 1/11/24 nurse progress note documented the resident refused his medications. The 1/13/24 nurse progress note documented the resident was agitated and yelled at staff. The 1/18/24 nurse progress note documented the resident was agitated during the night and had an altercation with another resident (#41). Cross-reference F600. The 1/19/24 nurse progress note documented the resident was agitated. Review of Resident #41's dependence on staff for meeting emotional, intellectual, physical, spiritual, and social needs related to Alzheimer's disease care plan, initiated 11/9/23, revealed the resident should be involved in cognitive stimulation and social programs. Pertinent interventions included resident enjoyed magazines, resident enjoyed visiting with others and his wife, resident liked to attend musical entertainment and walked around the facility, invite resident to musical performances and bingo. Review of Resident #41's elopement risk as a wanderer related to dementia care plan, initiated 11/4/23, revealed pertinent interventions included staff to distract resident from wandering with pleasant diversion, structured activities, food, conversation, television, and books. Review of Resident #41's impaired cognitive function with dementia or impaired thought process care plan, initiated 11/4/23, failed to include goals and interventions for resident's care needs. CNA #1 said the facility provided training for dementia care at staff meetings and during shift report. She said she understood resident's with dementia were frequently unable to communicate their needs. She said she was familiar with Resident's #21 and #41 and tried to anticipate their needs. She said Resident's #41 wandered a lot and responded well to staff when care was calm and one-to-one and Resident #21 preferred staff approached him slowly and explained care as it was provided. IV. Resident-to-resident altercation involving Residents #21 and #41 Resident 21 and Resident #41 were involved in an altercation on 1/18/24. Resident #21 walked in front of Resident #41 and Resident #41 pushed Resident #21 and caused him to fall on the floor (cross-reference F600). V. Staff interviews CNA #1 was interviewed on 1/25/24 at 3:27 p.m. She said she worked on 1/18/24 and was present but did not witness the altercation between Resident #21 and #41. She said Resident #21 was walking in the hallway near the nurses station. CNA #1 said when she turned her back at the ice machine, she saw Resident #21 near Resident #41 and then Resident #21 was on the floor. She said the altercation was fast and she did not see directly what happened. She said Residents #21 and #41 wandered the facility a lot but was unaware if either resident had prior history of behavior but hurting other residents. She said she knew to watch Residents #21 and #41 but they were not on a continuous line of sight program before the altercation on 1/18/24. CNA #3 was interviewed on 1/25/24 at 3:31 p.m. She said the facility provided training sometime around September 2023 about dementia which was about six hours long. She said the staff needed more training on dementia care especially when residents wandered into other rooms which caused physical altercations. CNA #1 said the facility provided training for dementia care at staff meetings and during shift report. She said she understood residents with dementia were frequently unable to communicate their needs. She said she was familiar with Residents #21 and #41 and tried to anticipate their needs. She said Resident #41 wandered a lot and responded well to staff when care was calm and one-to-one and Resident #21 preferred staff approached him slowly and explained care as it was provided. RN #1 was interviewed on 1/25/24 at 3:50 p.m. RN #1 said Resident #41 was sitting on a chair near her and as she prepared to administer his daily medication for anxiety on 1/18/24. She said she had her back turned to him and was a few feet away from him. She said she heard a noise and when she turned around, Resident #21 was on the floor. RN #1 said she completed a nursing assessment for Residents #21 and #41 and it determined neither resident was injured. She said she did not witness the altercation between Resident #21 and #41. She said after the altercation staff kept Resident #21 in a constant line of sight observation for safety. The director of nursing (DON) and the corporate consultant (CC) were interviewed on 1/23/24 at 4:05 p.m. The DON said the altercation between Residents #21 and #41 was unwitnessed. The DON said both Residents #21 and #41 had wandered inside the facility since they were admitted . She said staff have involved the residents in group and individual activities. -However, Residents #21 and #41 were unable to participate due to their cognitive status and should have had their plans of care updated to include appropriate activities for their level of cognition. The DON said Resident #41 had increased agitation when staff approached him so staff watched him from a distance. She said Resident #21 was not aggressive and had not harmed any residents in the facility. She said maybe Resident #21 wandered too close to Resident #41 as he sat on the chair which may have contributed to the altercation. The DON said on 1/19/23 the physician made a change to Resident #41's medications and that change was effective. The DON said non-pharmacological interventions were not considered for Resident #41 prior to the medication change. The DON said Resident #41 had no subsequent aggressive behaviors towards staff or residents. The DON said Resident #21 had a lot of anxiety and took anti-anxiety medication every day. She said Resident #21 wandered inside the facility daily. She said he allowed staff to provide close observation and he did well with one-to-one care. The DON said Resident #21 refused and resisted care and was agitated when he required toileting and hygiene care but was not aggressive towards residents. The DON said staff anticipated the needs of Resident #21 and no subsequent resident to resident altercations occurred. The DON said the physician would evaluate Residents #21 and #41 on 1/26/24 and she would ensure a review of interventions and medication effectiveness would be included in the physician's visit. The DON and CC said the MDS coordinator recently resigned and the DON updated care plans when she had time. The DON said the initial care plan was initiated by the MDS coordinator and then updated by the IDT when applicable. The DON said dementia care for each resident should have included goals and resident specific interventions on their initial care plan. The DON said when the resident had agitation and aggression, the IDT should have reviewed and updated the care plan with care goals and pertinent interventions.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs that accommodated resident allergies, intolerances and preferences. Specifically, the facility failed to: -Offer residents more options for alternative choices to the main meal; -Honor requests for items indicated on the alternative menu; and, -Offer the main dish sides with the alternative menu choice. Findings include: I. Resident interviews Resident #16 was interviewed on 1/22/24 at 2:55 p.m. She said the facility mainly served Mexican-styled food and she did not want that. She said the alternative meals were sandwiches and were usually served on stale bread. II. Resident group interview The resident group was interviewed on 1/23/24 at 1:42 p.m. with Resident #6, Resident #9, Resident #4, Resident #17, Resident #12 and Resident #13. Resident #17, Resident #4, Resident #12 and Resident #9 said if the residents wanted something else to eat off the bistro menu the staff got mad and the residents received the alternative meal of a sandwich. III. Observation The alternative meal offered for dinner on 1/24/24 was a roast beef and cheese sandwich or a peanut butter and jelly sandwich with potato chips and a fruit cup. -However, according there were more options according to the Bistro menu (the alternative menu, see below). IV. Bistro menu The Bistro menu was provided by the nursing home administrator on 1/22/24 at 4:05 p.m. The available meals were listed as: -Soup and sandwich; -Cottage cheese and fruit; -Peanut butter and jam sandwich; -Cheeseburger; -Chef salad; and, -Grilled cheese sandwich. V. Staff interviews The dietary manager (DM) was interviewed on 1/24/24 at 6:58 p.m. He said he was working with the registered dietitian (RD) to revamp the alternative menu to make them more suitable meals. He said the former DM made the anytime Bistro menu and most residents did not order from it. The DM said he was going to make a list of approximately 20 meals and let the residents vote on them but he had not done that yet. He said when residents ordered the alternative meal they were able to request the sides from the main meal. The DM said he explained that to the certified nurse aides (CNAs) but they did not write it on the meal tickets. The DM said he probably needed to remind the nursing staff again. He said the Bistro menu was available at any time for the residents to order from but if the kitchen staff were preparing meals they asked the residents to come back and request it later because they were busy with the main meal. He said the alternative meal was usually a sandwich and to most residents, a sandwich probably was not a substantial meal. Certified nurse aide (CNA) #3 was interviewed on 1/25/24 at 3:31 p.m. She said the CNAs took the menu to each resident's room and wrote down what they said they wanted to eat. She said if the resident was nonverbal the CNAs ordered the resident ' s meal based on what the CNAs knew they liked. CNA #3 said the anytime menu was listed on a separate menu but the alternative meal was usually a sandwich of some sort.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observations, interviews and record review, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to ensure: -The residents in the dining room did not have prolonged wait times of 30 minutes or longer for their meal to be served; and, -Room trays were delivered to all neighborhoods and served to the residents at the regular posted meal times. Finding include: I. Posted meal times Meal times were posted across the facility as the following: Breakfast at 8:00 a.m. Lunch at 12:00 p.m. Dinner at 5:00 p.m. II. Observations On 1/22/24 at 11:50 a.m., three residents were in the dining room waiting for lunch. -At 12:21 p.m. the first meal went to [NAME] Halls. -At 12:53 p.m. East Halls still had yet to be served their trays. -At 1:11 p.m. the meal cart was placed in the East Halls and the certified nurse aide (CNA) started serving C Wing first. -At 1:24 p.m. the meal cart went to the East Hall to serve D Wing. -At 1:35 p.m. all meals were served. -The meals were all served one hour and 35 minutes over the posted meal time. -There were activities scheduled for after lunch and residents arrived to them late because their lunch was served late. On 1/23/24 at 1:19 p.m. Resident #37 was in East Hall shaking his head and frowning. He said he had been waiting for his lunch. His meal arrived at 1:21 p.m. Resident #37 said he was not sure if he was going to be able to attend the resident group interview and physical therapy because his lunch was served late. He said he missed some appointments and activities because of late meals. On 1/24/24 at 4:41 p.m. the kitchen was finishing preparing the sides for dinner and making sure the food was up to serving temperature. -At 4:57 p.m. the kitchen staff waited to plate meals until CNAs were at the kitchen door to serve the plates. -At 5:02 p.m. the kitchen started plating the residents who ordered the alternative meal in the dining room. -At 5:10 p.m. a CNA asked the kitchen if they could plate Resident #21 because he was getting upset in the dining room. -At 5:11 p.m. Resident #21's plate had the wrong texture and the kitchen staff attempted to fix it but ran out of mechanical soft noodles and had to make more. -At 5:23 p.m. Resident #21's plate was sent to the dining room. -At 5:41 p.m. the dining room was served 41 minutes over the posted meal time and the kitchen staff began getting the meal cart ready for [NAME] Hall; Wing A and Wing B. -At 5:45 p.m. the [NAME] Hall meal cart was sent 45 minutes over the posted meal time and the kitchen staff prepared the meal cart for East Hall; Wing C and Wing D. -At 5:53 p.m. mechanical soft noodles were dropped on the floor and had to be remade. -At 6:11 p.m. the meal cart was sent to East Hall one hour and 11 minutes over the posted meal time. -At 6:14 p.m. Wing C was served one hour and 14 minutes over the posted meal time. -At 6:22 p.m. Wing D was served one hour and 22 minutes over the posted meal time. On 1/25/24 at 9:10 a.m. Resident #21 was self-propelling in his wheelchair and headed back to his room from the dining room. He said he was still waiting for his breakfast. He said all meals were late and most days he played a guessing game of which meal he would get first, breakfast or lunch. -The resident received his breakfast one hour and 10 minutes over the posted meal time. -At 12:53 p.m. East Halls still had yet to be served their trays. Resident #37 self-propelled in the hallway while waiting for his lunch. He said he was hungry and looked to see if the meal cart was leaving the kitchen yet. -The resident's lunch arrived at 1:09 p.m. one hour and nine minutes over the posted meal time. III. Resident interviews Resident #9 was interviewed on 1/22/24 at 2:34 p.m. She said she ate in her room and meals were getting served later and later. She said hot foods and cold foods were lukewarm by the time they were served to the halls. She said the dessert was usually an individual ice cream and was usually melted by the time it was served in the rooms. IV. Resident group interview The resident group was interviewed on 1/23/24 at 1:42 p.m. with Resident #6, Resident #9, Resident #4, Resident #17, Resident #12 and Resident #13. Resident #9 and Resident #13 arrived late due to being served their lunch late and needing to eat. The group said meals were late and foods were served cold and residents were not woken up for breakfast which made their food even colder. The group said when the residents told staff their food was cold the staff told them I am sorry there is nothing I can do. The group said when the meals were served late it affected their schedules and made them feel terrible. Resident #4 said it upset her because then she felt like it was her fault she was late for something she had scheduled because her meal was late. V. Staff interviews The dietary manager (DM) was interviewed on 1/24/24 at 6:58 p.m. He said the posted meal times were when he had the kitchen start plating the meals. The DM said it did not necessarily mean that was when the meals were to be served. He said meals were sometimes late because he had a new team in the kitchen and they were trying to get a better flow. CNA #3 was interviewed on 1/25/24 at 3:31 p.m. She said when dinner was posted for 5:00 p.m. she said plates should be served to the residents at 5:00 p.m. She said most of the time the halls did not get the meal carts until 6:30 p.m. She said the residents were really angry when they waited for their meals.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to act promptly upon the grievances in the resident council meeting. Specifically, the facility failed to document and respond to the resident council's grievances over the past four months regarding nursing care and dietary concerns. Findings include: I. Facility policy The Filling Grievances or Complaints policy, revised April 2017, was provided by the nursing home administrator (NHA) on 1/25/24 at 10:40 a.m. read in pertinent: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff. -Any resident, family member or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior fo other residents, staff members, theft of property or any other concerns regarding his or her stay at the facility. -Grievances may also be voiced or filed regarding care that has not been furnished. -All grievances, complaints or recommendations stemming from residents or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. -Upon receipt of a grievance or complaint, the grievance officer will review and investigate the allegations and submit a written report such as findings to the administrator within five working days of receiving the grievance or complaint. -The grievance officer, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation if being investigated. -The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken. -The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. II. Resident group interview The resident group was interviewed on 1/23/24 at 1:42 p.m. with Resident #6, Resident #9, Resident #4, Resident #17, Resident #12 and Resident #13. A frequent visitor of the facility attended the group interview. The frequent visitor said grievances were not followed up on and had not been since at least September 2023. One grievance was filed by Resident #12 for the brief liners not being good enough because residents who had issues with incontinence leaked through the liners. Resident #12 said the director of nursing (DON) stopped ordering them and told the residents it was because the State Agency said they were not allowed to be used. The resident council president said she wanted to be able to use them and some of the certified nurse aides (CNAs) used a brief to make a liner inside of her brief to find a temporary solution. The frequent visitor said another grievance filed was by a former resident who said the CNAs were not using gait belts properly. The gait belts were placed across the resident's chest, over her breasts instead of under them. When the resident reported it to the staff the staff responded with I am sorry there is nothing I can do about that. Resident #17, Resident #4 and Resident #12 said they filed a grievance for not being told about their appointments in writing or ahead of time. The residents said they were told about their appointments approximately an hour before their appointment and refused to go because they had other things scheduled or did not have time to get ready. Resident #17, Resident #4, Resident #6, Resident #9 and Resident #12 said another grievance filed was the nursing staff, mainly CNAs, had attitudes toward the residents and when the CNAs answered call lights they turned the light off and said they would be right back but never returned. Resident #17 said when she used her call light the CNAs entered the room and rudely said, Again or What do you need now. She said it made her not want to use her call light. Resident #12 and Resident #4 said a grievance was filed for the CNAs [NAME] up soiled briefs and throwing them on the floor or placing them on the residents' bed and leaving the room or leaving them in the trash can and the trash can not be emptied. The residents said they started leaving their trash cans outside the door to their room so someone would empty them. Resident #17, Resident #4 and Resident #9 said they filed a grievance for food being served cold and when the residents asked staff to warm the plates back up the staff said I am sorry, there is nothing I can do. The group said they were not receiving condiment packets with their food and filed a grievance for it. The resident council president said none of the grievances had been followed up on by any departments. The group said they wanted someone from each department to attend the resident council meetings so the residents were able to ask their questions directly but the AD and dietary manager (DM) were the only staff who showed up. The group said they felt like no one was listening to them or taking their grievances seriously. The residents said they felt unimportant to the facility. III. Resident council notes A. 9/26/23 A review of the September 2023 resident council minutes revealed the activities director (AD) documented grievances were filed for: -Brief liners not good enough; -Gait belts not placed properly; -Dirty briefs being thrown on the floor or left on the bed; -Residents not being informed of appointments in writing; -Food being served cold; and, -Condiments not available when requested. B. 10/31/23 A review of the October 2023 resident council minutes revealed old business was documented as the courtyard construction was coming along and looked good. -The AD did not follow up on the grievances from 9/26/23 and no grievances were filed for October 2023. C. 11/28/23 A review of the November 2023 resident council minutes revealed there was no old business to discuss. The notes documented grievances were filed for: -A resident wanted his medications by 7:00 p.m. He wanted to take his medications and go to bed without being disturbed; -Call lights were being shut off by the CNAs and the CNAs never returned to answer the call light; and, -Residents wanted a certain brief liner to be ordered for the facility again. D. 12/26/23 A review of the December 2023 resident council minutes revealed there was no old business to discuss. A note was documented under the nursing and CNA section the department was doing well and two grievances that were filed in November 2023 had been resolved. -However, the facility did not explain to the residents or document which grievances were resolved and what the outcome or findings were. IV. Staff interviews The NHA was interviewed on 1/25/24 at 7:08 p.m. She said the AD was the facilitator for the resident council. She said the department heads attended the resident council meeting if they were invited ahead of the meeting but they did not attend routinely. The social services director (SSD) was interviewed on 1/25/24 at 7:27 p.m. She said she was the grievance officer and when grievances were filed she delivered the forms to the corresponding department for them to follow up on and worked with the department to resolve the grievance. She said the departments investigated the grievances immediately. She said the AD took care of the grievances and when the grievances were taken care of they were sent back to the SSD. The SSD and AD were interviewed on 1/25/24 at 8:20 p.m. They said they did not realize the grievances from the resident council were not followed up on. The AD said she delivered the grievances to each department and they were to resolve the situation. She said she did not keep a copy of the grievances and did not realize the old business section on the resident council note form should have been filled out with previous grievances to ensure they were followed up on and resolved. The SSD said she and the AD were going to work together to ensure grievances were taken care of but they needed help and support from the NHA. The SSD said she was going to make a binder for the resident council minutes and a copy of the grievances filed so she would be more organized and could keep track of the grievances. The AD said the residents requested someone from each department to attend the resident council meetings but no one showed up except herself and the DM. The SSD said she felt it was important that each department was represented in the resident council if the group wanted them to attend. The SSD said the ball was dropped on grievances from the resident council.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure freedom from resident-to-resident abuse involving four (#33, #201, #21 and #41) of five residents reviewed for abuse out of 33 sample residents. Specifically, the facility failed to: -Investigate and implement measures to prevent altercations between Resident #33 and Resident #201 on 2/20/23 and 6/7/23; -Prevent resident-to-resident abuse involving Resident #33 and Resident #201 on 8/6/23, 8/16/23 and 9/16/23; and, -Prevent resident-to-resident abuse involving Resident #21 and #41 on 1/18/24. Findings include: I. Facility policies The Resident Abuse Prevention policy, revised August 2017, was provided by the nursing home administrator (NHA) on 1/22/24 at 9:00 a.m. and read in pertinent part: The community will not tolerate any form of abuse, neglect or exploitation of our residents. This policy is to assure that allegations of abuse, neglect or exploitation are identified, investigated, reported, documented and followed up with interventions to prevent reoccurrence and assure protection. Freedom from Abuse and Neglect: each resident has the right to be free from physical, mental or sexual abuse, neglect, corporal punishment, involuntary seclusion, and physical or chemical restraints. Procedure: All employees who have reason to suspect a resident has suffered abuse are responsible for reporting that information to the executive director (ED) or upon his or her absence, to a supervisor. If to a supervisor, he or she shall pass along the information to the ED immediately. Protect the resident: Any resident involved must be protected during the course of the investigation through appropriate means as determined by the ED including but not limited to increased resident supervision by staff or family presence. Investigate: ED or designee will initiate the investigation immediately and complete the investigation within thirty days. The investigation will utilize the Abuse Investigation Report Form for documentation of the events, investigation, reporting as indicated below and documentation of actions taken and perform a thorough investigation. The Abuse and Neglect policy, revised September 2018, provided by the nursing home administrator (NHA) on 1/22/24 at 2:30 p.m. read in pertinent part, Every resident has the right to be free from physical abuse. II. Resident-to-resident altercations involving Resident #33 and Resident #201 A progress note was entered in Resident #33's chart on 2/20/23. It was documented at approximately 6:20 p.m. Resident #33 was noted to be verbally aggressive toward Resident #201 (who passed away) as they passed in the hallway by the dining room. A staff member was present and separated the two residents. Resident #201 showed no indication of hearing or understanding what Resident #33 said. Resident #33 told staff she had nightmares all night because that man was in my doorway last night and she told him to get away. Resident #33 was counseled by staff that threatening other residents was not the way to handle the situation. Resident #33 continued to be verbally aggressive regarding Resident #201. Resident #33 calmed down and enjoyed a game of Rumicube in the activity room. At approximately 8:50 p.m., Resident #33 was overheard telling three other residents, I told that man to stay out of my room, he did not listen so I took my hairbrush and I told him if he comes in my room again I will shove this down his throat while the residents were in the activity room. -The facility failed to investigate Resident #33 making threatening statements about Resident #201 and implement measures to protect him. A progress note entered on 6/7/23 documented in Resident #33's chart that she was in another resident-to-resident incident. Resident #201 entered Resident #33's room and staff heard Resident #33 yelling from her room. The nurse went into the room and saw Resident #33 with a water jug in her hand and water was all over the bed. Resident #201 was seen with his hand on Resident #33's shoulder. The nurse assessed Resident #33 and noted no redness or bruising to her right shoulder. Resident #33 told the nurse that Resident #201 did not hurt her but she was scared of him and wanted to go home. The nurse contacted Resident #33's representative and he said the resident could not return home at the time. The executive director (ED) was notified at 5:37 p.m. and the director of nursing (DON) was notified at 5:48 p.m. -The facility failed to investigate Resident #33's statements of being scared of the resident and implement measures for her safety. A progress note entered on 8/6/23 documented in Resident #33's chart that she was involved in an altercation with another resident in the main dining room. A facility investigation began on 8/6/23. It documented Resident #33 was sitting in the main dining room and Resident #201 was walking in her direction. Resident #33 started yelling at Resident #201 in the main dining room for him not to come over to where she was and that she was going to throw water on him. Resident #33 began to get up out of her seat with a glass of water in one hand and her other hand was balled up into a fist. The dietary aide (DA) who saw what was happening went to get a nursing staff member at the nurses' station. When the DA turned around he saw Resident #201 was wet and Resident #33 was swinging her fist hitting Resident #201 with a closed fist. Resident #33 struck Resident #201 on the shoulder, chin, lower jaw and the top of his head which caused a cut to his left cheek. Resident #201 swung back at Resident #33 with an open hand which caused a small red area to Resident #33's upper left eyebrow. Resident #201 was not interviewed during the investigation due to his impaired cognition and nonsensical verbal communication. -The facility substantiated the abuse had occurred. A progress note entered on 8/16/23 in Resident #33's chart documented Resident #201 got into Resident #33's room. Resident #33 said she hit Resident #201 with the plastic bristle side of her hair brush. Resident #201 sustained a 0.2-centimeter laceration to the right side of his nose. No injuries were noted on Resident #33. A facility investigation began on 8/16/23. It documented that the staff heard yelling and went to Resident #33's room. When the staff entered the resident's room she saw Resident #33 was hitting Resident #201 in the face with the bristles of Resident #33's hairbrush. The staff immediately assisted Resident #201 from Resident #33's room to his own room. Resident #33 told staff Resident #201 entered her room and she got scared so she hit him. Resident #33 denied that Resident #201 did anything other than walk into her room. -The facility substantiated the abuse had occurred. A progress note was entered into Resident #33's chart on 9/17/23 at 12:40 a.m. It documented a certified nurse aide (CNA) heard Resident #33 scream from her room and saw Resident #201 in Resident #33's room. The CNA said Resident #33 hit Resident #201 with a water pitcher. Resident #33 held Resident #201's sweater and pulled him down resulting in both residents going to the floor. Resident #33 ended up on the floor and Resident #201 was down on his knees. At 2:26 a.m. a progress note documented Resident #33 had an altercation with another resident which resulted in her having a bump on the back of her head. The bump measured approximately four and a half centimeters by four centimeters and was raised half of a centimeter initially. The last assessment resulted in the bump getting better and was no longer raised but it was still tender to the touch. A facility investigation began on 9/16/23. It documented the incident had occurred on 9/16/23 at 6:45 p.m. (However, the progress note was not documented until 9/17/23 at 12:40 a.m.) It was documented Resident #201 walked into Resident #33's room. The staff immediately entered Resident #33's room to intervene. The staff saw Resident #33 hitting Resident #201 with her water pitcher and she was holding Resident #201 by his sweater with her other hand. The CNA approached to assist and Resident #33 lost her balance, fell to the floor and pulled Resident #201 to the floor with her which caused him to land on his knees. -The facility substantiated the abuse had occurred. III. Resident #33 A. Resident status Resident #33, age over 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included unspecified head injury, altered mental status, weakness and unspecified abnormalities of gait and mobility. According to the 11/20/23 minimum data set (MDS) assessment Resident #33 had a mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. Resident #33 had no behaviors documented on the assessment. B. Record review Resident #33's care plan, revised on 7/26/23, documented the resident's request for a stop sign in front of her door to stop residents from entering her room. The interventions were to place a stop sign in front of her doorway, review Resident #33's request for the stop sign as needed, make sure the stop sign was in place upon leaving the resident's room and one-to-one monitoring for Resident #33 until further notice. A focus area for Resident #33's potential for unprovoked agitation toward other residents was initiated on 8/6/23. The interventions, revised on 8/21/23, were documented as the resident was being referred to a counselor to discuss her fearfulness of others, Resident #33 had a line-of-sight supervision level any time she was out of her room or in the common areas and Resident #33 was placed on one-to-one supervision when she was out of her room or in the common areas. -The facility failed to consistently implement interventions after each incident to prevent abuse from occurring again. IV. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 1/25/24 at 3:31 p.m. She said the facility provided training sometime around September 2023 about dementia which was about six hours long. She said the staff needed more training on dementia care especially when residents wandered into other rooms which caused physical altercations. She said an incident occurred where Resident #201 entered Resident #33's room. CNA #3 heard another CNA yelling for help and she provided assistance. She said when she entered the room Resident #33 was fuming and standing up while Resident #201 was on the floor covered in water. CNA #3 said Resident #33 had hit Resident #201 and it was not the only incident the two residents had with each other that she was aware of. The director of nursing (DON) was interviewed on 1/25/24 at 4:10 p.m. She said she did not investigate abuse and the abuse coordinator was the nursing home administrator (NHA). She said if she received a report of abuse she separated the residents and interviewed each resident if they were interviewable. She interviewed each staff member individually to find out what occurred. She said the facility typically placed the aggressor on one-to-one supervision. She said the interdisciplinary team (IDT) discussed interventions to prevent the abuse from reoccurring. She said it was important to find out who was the victim and the aggressor and try to figure out why the incident occurred. The DON said staff did not provide enhanced supervision to Resident #33 because she rarely left her room anymore and it was not needed. -However, the facility failed to revise Resident #33's care plan when there were instances of abuse between Resident #33 and Resident #201. The NHA was interviewed on 1/25/24 at 5:07 p.m. She said if a resident was afraid of another resident the incident was investigated as abuse. She said she would have reported the incident as abuse whether it was physical abuse or verbal abuse. She said she was on vacation when the 2/20/23 incident occurred and the DON covered for her as the abuse coordinator. She said the DON should have investigated and reported the incident. She said she was working when the 6/7/23 incident occurred and was not sure why the incident was not investigated or reported. The NHA said the abuse between Resident #33 and Resident #201 was no longer an issue when Resident #201 passed away. V. Resident-to-resident altercation involving Resident #21 and Resident #41 Review of the 1/18/24 nurse progress notes for Residents #21 and #41 and a facility investigation revealed an altercation occurred between Resident #21 and #41. The altercation resulted in Resident #21 falling to the floor. The altercation was unwitnessed although two staff members, a registered nurse (RN) and certified nurse aide (CNA) were in the area. The nurse progress note documented Resident #21 walked in front of Resident #41 and Resident #41 pushed Resident #21 causing him to fall to the floor. Residents #21 and #41 were not interviewable due to their impaired cognitive status. The facility investigation documented a staff member, using peripheral vision, saw that Resident #21 fell and landed on his buttocks. The 1/18/24 nurse assessment documented Resident #21 was not injured from the fall. -According to the facility investigation, the abuse was substantiated. VI. Resident #21 A, Resident status Resident #21, over the age of 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included unspecified dementia with unspecified severity with behavioral disturbance and anxiety. The 11/21/23 minimum data set (MDS) assessment documented Resident #21 had severe cognitive impairment, was rarely or never understood, and was unable to complete the brief interview for mental status (BIMS). He had delirium symptoms including inattention and disorganized thinking. He had mood symptoms that included little interest or pleasure in doing things, trouble concentrating on things, such as reading the newspaper or watching television. He experienced delusions. He had physical and verbal behavioral symptoms directed toward others and directed towards others and wandering behavior. He was dependent on staff assistance for toileting and hygiene, showering, dressing, oral hygiene, required supervision for bed mobility and transfers, ambulation, and eating. The resident was prescribed antipsychotic, antianxiety and antidepressant medications at the time of the assessment. B. Record review Resident #21's care plan, initiated on 11/10/23, included a focus for behavior for actual or potential for alteration in mood and agitation, and may break items in his room. Interventions included: -Assist the resident, family, caregivers, to identify strengths and positive coping skills; and, -Identify approaches based on causal and contributing factors for the resident's behaviors. The nurse progress notes documented on 11/18/23, 11/21/23, 12/9/23, 12/2/23, 12/27/23, 1/2/24, 1/13/24, 1/12/24, 1/13/24, 1/17/24, 1/20/24, 1/21/24 and 1/22/23 the resident was agitated, physically aggressive and combative with staff, broke furniture in his room, wandered into other rooms, urinated on the floor, crawled on the floor and touched and grabbed staff and other residents. -However, the facility failed to update the care plan for the resident's behavior. The resident's care plan, updated 1/23/24, documented the resident was at risk of being a victim of resident-to-resident altercations due to cognition level, nonsensical speech pattern and inability to recognize the personal space of others. -However, the care plan failed to include interventions for care. Cross-reference F744 for failure to implement personalized care interventions for dementia care. VII. Resident #41 A. Resident status Resident #41, over the age of 65, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included Alzeheimer's disease and unspecified dementia with unspecified severity without behavioral disturbance. The 11/10/23 MDS assessment documented the resident had severe cognitive impairment as evidenced by a BIMS with a score of four out of 15. He had delirium indicators continuously present of inattention and disorganized thinking. He needed supervision and setup assistance from staff for personal and toilet hygiene. B. Record review -Review of Resident #41's impaired cognitive function with dementia or impaired thought process care plan, initiated 11/4/23, failed to include goals and interventions for the resident's care needs and was not updated after the 1/18/24 altercation with Resident #21. The nurse progress notes documented on 11/4/23, 11/20/23, 11/26/23, 12/16/23, 12/17/23, 12/19/23, 1/1/24, 1/11/24, 1/12/24, 1/13/24, 1/18/24 and 1/19/23 the resident wandered inside the facility and entered other resident rooms, had agitation, yelled, was verbally aggressive with staff, angry and grabbed at a CNA, removed his soiled pajamas in another room, left his room without pants or underwear, refused care and occasionally refused medications. -The resident's care plan failed to include a focus for care on the resident's behaviors. Cross-reference F744 for failure to implement personalized care interventions for dementia care. VIII. Staff interviews CNA #1 was interviewed on 1/25/24 at 3:27 p.m. She said she worked on 1/18/24 and was present but did not witness the altercation between Resident #21 and #41. She said Resident #21 was walking in the hallway near the nurses station. CNA #1 said when she turned her back at the ice machine, she saw Resident #21 near Resident #41 and then Resident #21 was on the floor. She said the altercation was fast and she did not see directly what happened. She said Residents #21 and #41 wandered the facility a lot but she was unaware if either resident had prior history of hurting other residents. She said she knew to watch Residents #21 and #41 but they were not on a continuous line of sight program before the altercation on 1/18/24. RN #1 was interviewed on 1/25/24 at 3:50 p.m. RN #1 said Resident #41 was sitting on a chair near her as she prepared to administer his daily medication for anxiety on 1/18/24. She said she had her back turned to him and was a few feet away from him. She said she heard a noise and when she turned around, Resident #21 was on the floor. RN #1 said she completed a nursing assessment for Resident #21 and #41 and determined neither resident was injured. She said she did not witness the altercation between Resident #21 and #41. She said after the altercation staff kept Resident #21 in a constant line of sight observation for safety. The director of nursing (DON) and the corporate consultant (CC) were interviewed on 1/23/24 at 4:05 p.m. The DON said the altercation between Residents #21 and #41 was unwitnessed. The DON said both Residents #21 and #41 had wandered inside the facility since they were admitted . She said staff had involved the residents in group and individual activities. -However, Residents #21 and #41 were unable to participate due to their cognitive status and should have had their plans of care updated to include appropriate activities for their level of cognition. The DON said Resident #41 had increased agitation when staff approached him so staff watched him from a distance. She said Resident #41 was not aggressive and had not harmed any residents in the facility. She said Resident #21 could have wandered too close to Resident #41 as he sat on the chair which may have contributed to the altercation. The DON said on 1/19/23 the physician made a change to Resident #41's medications and that change was effective. The DON said non-pharmacological interventions were not considered for Resident #41 prior to the medication change. The DON said Resident #41 had no subsequent aggressive behaviors towards staff or residents. The DON said Resident #41 had a lot of anxiety and took anti-anxiety medication every day. She said Resident #41 wandered inside the facility daily. She said he allowed staff to provide close observation and he did well with one-to-one care. The DON said Resident #41 refused and resisted care and was agitated when he required toileting and hygiene care but was not aggressive towards residents. The DON said staff anticipated the needs of Resident #41 and no subsequent resident to resident altercations occurred. The DON said the physician would evaluate Residents #21 and #41 on 1/26/24 and she would ensure a review of interventions and medication effectiveness would be included in the physician's visit. The DON and CC said the MDS coordinator recently resigned and the DON updated care plans when she had time. The DON said the initial care plan was initiated by the MDS coordinator and then updated by the IDT when applicable. The DON said dementia care for each resident should have included goals and resident specific interventions on their initial care plan. The DON said when the resident had agitation and aggression, the IDT should have reviewed and updated the care plan with care goals and pertinent interventions.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive at the appropriate temperatures and met the nutritional needs of the residents. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and appearance. Findings include: I. Resident interviews Resident #11 was interviewed on 1/22/24 at 12:15 p.m. He said the food was not good. He said he did not like the food the facility prepared. He said if cauliflower was served it was just cauliflower stems and they were tough. He said he loved over-easy eggs but received scrambled eggs a lot. Resident #11 said he started buying personal food to eat when he was served something he did not like. Resident #9 was interviewed on 1/22/24 at 2:34 p.m. She said she ate in her room and meals were getting served later and later. She said hot foods and cold foods were lukewarm by the time they were served to the halls. She said the dessert was usually an individual ice cream and was usually melted by the time it was served in the rooms. Resident #16 was interviewed on 1/22/24 at 2:55 p.m. She said the facility mainly served Mexican-styled food and she did not want that. She said the alternative meals were sandwiches and were usually served on stale bread. II. Resident group interview The resident group was interviewed on 1/23/24 at 1:42 p.m. with Resident #6, Resident #9, Resident #4, Resident #17, Resident #12 and Resident #13. Resident #9 and Resident #13 arrived late due to being served their lunch late and needing to eat. The group said meals were late and foods were served cold and residents were not woken up for breakfast which made their food even colder. The group said when the residents told staff their food was cold the staff told them I am sorry there is nothing I can do. The group said when the meals were served late it affected their schedules and made them feel terrible. Resident #4 said it upset her because then she felt like it was her fault she was late for something she had scheduled because her meal was late. Resident #17, Resident #9 and Resident #4 said if they wanted something else to eat off the bistro menu the staff got mad and the residents received the alternative meal of a sandwich. III. Dinner test tray A test tray was received on 1/24/24 at 6:37 p.m., two evaluators tested the dinner tray. Dinner on the menu was potato mushroom soup, crab alfredo with linguine, lemon cream salad, roasted asparagus, and a slice of banana bread. Dinner on the test tray was crab alfredo with linguine, mixed vegetables and vanilla brioche bread with a banana cream sauce. The kitchen substituted the lemon cream salad, roasted asparagus, and banana bread for the meal. The kitchen ran out of the potato mushroom soup for the final resident's meal tray and the test tray. The linguine noodles were oily and had clumps of overcooked noodles with hard, crunchy pieces. The mixed vegetables contained carrots, lima beans, and other unidentifiable vegetables. The vegetables were overcooked, mushy and not flavorful. There was no seasoning and the vegetables did not taste like vegetables. The banana cream sauce on the vanilla brioche bread was no longer cold, it was lukewarm and had an odd texture to it. IV. Staff interviews The dietary manager (DM) was interviewed on 1/24/24 at 4:50 p.m. He said the kitchen staff substituted asparagus for mixed vegetables and the vanilla brioche bread with banana cream sauce for the banana bread. He said the kitchen had to make changes to the menu but did not say why, but substituted items on the menu when the kitchen did not have the items on hand. The DM was interviewed again on 1/24/24 at 6:58 p.m. He said he was working with the registered dietitian (RD) to revamp the menu to make more suitable menu items. He said he asked the RD when the kitchen needed to substitute menu items for each meal. The DM said the kitchen ran out of items or had the wrong ingredients so had to substitute some menu items. The DM said he was working on a list of menu items for the residents to vote on to add to the menu and alternative menu. The DM said he planned on having the residents vote on the options the following week of 1/29/24 so he had not completed it yet. The DM told the residents from the resident council that the kitchen was working on making meals from scratch as a follow-up to their food grievances. -However, residents grievances were not followed up consistently (cross-reference F565 for resident group response).

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents or their representative were aware of the nature and implications of the facility's arbitration agreement to inform their decision on whether or not to enter into such agreements for six residents (#21, #22, #36, #42, #43 and #46) of six out of 32 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure residents and/or resident representatives understood the agreement before signing the arbitration agreement; -Accurately inform residents and/or resident representatives when the agreement could be rescinded before the agreement was signed; and, -Ensure staff reviewing the arbitration agreement with residents and the residents' representatives understood the components of the agreement. Findings include: I. The Arbitration Agreement The Voluntarily Executed Mutual Arbitration Agreement, undated, was provided by the nursing home administrator (NHA) on 1/22/24. The agreement read in part: This document waives the right to a trial by judge or jury: read carefully. Your decision to enter this agreement is voluntary and not a condition of admission to the community. However, once executed, the agreement requires arbitration of claims as defined and explained below. Agreement to arbitrate. Arbitration is a cost effective, private and time saving alternative means of resolving disputes outside of the courts. The dispute is heard and decided by a neutral arbitrator selected by the parties, rather than a judge or jury. This agreement does not waive or limit any party's right to assert claims against the other party, but rather provides an alternative venue for those claims to be resolved. By executing this agreement, the resident and community agree that any and all actions, claims, controversies, or disputes of any kind whether in contract or tort, statutory or common law personal injury property damage, legal or equitable, or otherwise, either currently existing or arising in the future, arising out of or relating in any way to the to the provision of assisted living, skilled nursing or healthcare services or any other goods or services provided under the terms of any agreement between the parties, including disputes involving the scope of this agreement, or any other dispute involving acts or omissions that cause damage or injury to either party and including wrongful death and survival actions, and where the amount in controversy exceeds $25,000 (collectively,'Claims'), shall be resolved exclusively by binding arbitration and not by lawsuit or the judicial process (except to the extent that applicable law provides for judicial review of arbitration proceedings). The resident has the right to seek legal counsel concerning this agreement, and has the right to rescind this agreement by written notice to us within 90 days after the agreement has been signed and executed by both parties unless said agreement was signed in contemplation of the resident being hospitalized in which case the agreement may be rescinded by written notice to us within 90 days after release or discharge from the hospital or other health care institution. Both parties to this agreement, by entering it, have agreed the use of binding arbitration in lieu of having any such dispute decided in a court of law before a jury. The agreement shall continue in full force and effect beyond the residents' stay at the community and shall survive death of the resident and the existence or operation of the community. The agreement shall be binding on this and all subsequent admission/readmissions to, or transfers within, the community. If any provision, sentence, word, phrase, paragraph, or portion of this agreement is declared to be unlawful, invalid or unenforceable for any reason, the remaining terms and provisions of this agreement show remain in full force and effect. The parties acknowledge agree that: -The community has explained this agreement to the resident and his/her legal representative, if present and provided the resident and his or her legal representative with an opportunity to ask questions; -Each party has executed this agreement on their own free will and without corrosion or distress from the other; -The resident has been informed of the legal right to seek legal counsel concerning this agreement at his or her own cost; -Execution of the agreement is not a precondition of residency or to the receipt of services from the community; and, - The community has provided a copy of the fully executed agreement to the resident and or his legal representative. This agreement contains a binding arbitration provision which may be enforced by the parties. By signing this agreement, the parties understand and agree that they are relinquishing and waiving their right to have any claim decided in court of law before a judge or a jury. Instead, disputes between the parties shall be resolved by the binding arbitration agreement. By signing this agreement you are agreeing to have any issue of medical malpractice decided by neutral binding arbitration rather than by a jury or a court trial. II. Staff interview The NHA was interviewed on 1/24/24 at 2:10 p.m. The NHA said the facility asked residents and /or the residents' representatives to enter into an arbitration agreement. She said the agreement was included in the admission packet. The arbitration agreement was reviewed with residents and or the residents' family representatives on admissions with the social service director (SSD). The social service director (SSD) was interviewed on 1/24/23 at 2:25 p.m. The SSD identified herself as the family advisor and was responsible for reviewing new admission paperwork with residents and/or the resident's representative/family. She said she had been reviewing arbitration agreements with the new admission residents and/or their representatives for at least a couple of years. The SSD said the arbitration agreements were not a condition for admission to the facility. Resident #43's arbitration agreement was reviewed with the SSD. The resident signed his own arbitration agreement. The SSD said Resident #43 had a recent and significant increase in his confusion. She said when the resident was admitted to the facility in November 2023 he seemed cognitively intact. The SSD said the resident or the resident representative would sign the agreement based on the resident's cognition to determine who would sign the electronic documents. The SSD said during the admission process she did not review the hard copies of the arbitration agreement with the resident and/or the resident representative. The SSD said the agreement was on her computer. She said she would briefly explain the agreement and then had the resident or their representative sign the agreement electronically. The resident or their representative could have a copy of the agreement if they wanted one. The SSD said she reviewed the arbitration agreement with the residents and/or the residents representatives by telling them not to go to court. She said to let the facility know if there were any concerns so the facility could fix it. The SSD said her understanding of the arbitration agreement was to address grievances. She said she wanted the residents and their families to feel comfortable with telling the facility their concerns/complaints. The SSD said if the concerns were not able to be resolved in the facility, the residents and/or representatives were informed then the resident/representative and the facility would address the concerns in mediation. The SSD said the residents and/or the residents' representatives could rescind the agreement but she was not sure the details to rescind or the exact time period when the residents and/or the residents' representatives could rescind the agreement. She said she felt residents could complain at any time so she did not give them a timeline. She said when she reviewed the arbitration agreement, she reviewed it more as a grievance process. The SSD said residents and/or the resident's representatives may still go to court to settle a dispute with the facility after signing the agreement. The SSD said first there was meditation to attempt to resolve and then there would be an option to go to court. She said the residents and their representatives could still do what they want after signing the arbitration agreement. The SSD reviewed the arbitration agreement she provided the residents and/or the representatives. The SSD said she had been misinterpreting the arbitration agreement when reviewing it with the residents and/or their representatives. The SSD said she probably should read the agreement in detail. She said she thought the agreement was just about the resident's right to complain. She said she thought that if the resident and/or representative signed the agreement, they still had the right to sue. She said according to the arbitration agreement by signing the agreement, the right to court was waived. The SSD said she did not know residents and/or representatives had only 90 days to rescind the agreement. She said she did not tell the residents and/or representatives they had only 90 days to change their mind after signing the agreement. The SSD said she needed time to sit down and read the complete admissions packet the residents and/or representatives sign. She said she was not trained on all the admission paperwork including the arbitration agreement. She said she had another admission this afternoon (1/24/24) and now had a better idea on what to tell the admission about the arbitration agreement. The NHA was interviewed on 1/24/24 at 3:05 p.m. The NHA said all but one resident in the facility had a signed arbitration agreement in place. The NHA was interviewed again on 1/24/24 at 5:52 p.m. The NHA said she was only involved in the arbitration process if a resident requested to go into arbitration. She said her understanding of the agreement was a resident had 90 days to rescind the arbitration agreement after it was signed. The resident or resident representative would go into mediation to review the dispute between the facility and the resident or representative instead of first going through the court system. The NHA said the resident could still go to court with an arbitration agreement in place but she was not totally sure. The NHA said she was not aware of the amount of facility admission training the SSD had or who provided her with the training to complete admission paperwork but the SSD had been in role for a while. III. Record review The facility admission packet was provided by the NHA on 11/13/23. The admission packet included the binding arbitration agreement. Arbitration agreements for Resident #21, Resident #22, Resident #36, Resident #42, Resident #43 and Resident #46 were provided by the facility on 1/24/24. Two of the signed agreements were signed by the resident representative. Four of the arbitration agreements were signed by the resident. All the arbitration agreements were signed by the SSD as the facility representative. The following arbitration agreements were reviewed: Resident #21 was admitted to the facility on [DATE]. The arbitration agreement was signed by Resident #21's representative on 11/12/23. The arbitration agreement was signed by the SSD on 11/12/23. Resident #22 was admitted [DATE]. According to the 12/7/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for a mental status (BIMs) score of six out of 15. The arbitration agreement was signed by Resident #22 on 12/4/23. The arbitration agreement was signed by the SSD on 12/4/23. Resident #36 was admitted [DATE]. The arbitration agreement was signed by Resident #36's representative on 12/21/23. The arbitration agreement was signed by the SSD on 12/21/23. Resident #42 was admitted on [DATE] and readmitted to the facility 12/5/23 after a 11/27/23 discharge. According to the 11/15/23 MDS assessment, the resident was cognitively intact with a BIMs score of 15 out of 15. The arbitration agreement was signed by Resident #42 on 11/12/23 and again on 12/6/23. The arbitration agreement was signed by the SSD on 11/12/23 and again on 12/6/23. Resident #43 was admitted [DATE]. According to the 11/30/23 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. The arbitration agreement was signed by the Resident #43 on 11/24/23. The arbitration agreement was signed by the SSD on 11/24/23. Resident #46 was admitted [DATE]. According to the 1/2/24 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The arbitration agreement was signed by the Resident #46 on 12/28/23. The arbitration agreement was signed by the SSD on 12/28/23. IV. Representative interviews The representative of Resident #36 was interviewed on 1/25/24 at 9:24 a.m. The terms of the arbitration agreement were not reviewed with him. The representative said was provided with a copy of the agreement but had not read it thoroughly yet. He said he had a basic understanding of what arbitration was but was not aware he had only 90 days to change his mind after signing the agreement. He said he signed the agreement in December 2023 and was happy to know about the deadline and still had to rescind the agreement if he chose to. The representative of Resident #21 was interviewed on 1/25/24 at 11:10 a.m. The representative said she did not remember the facility going over an arbitration agreement when she admitted Resident #21 to the facility. She said she agreed verbally to a lot of things during the admission process but she did not actually sign anything including an arbitration agreement. The representative said she did not get a copy of the arbitration agreement. She said if something happened to Resident #21 during his stay at the facility she would like the option to go to court. V. Resident interviews Resident #43 was interviewed on 1/22/24 at 10:46 a.m. The resident was able to make basic needs known during the interview but was not able to answer questions regarding his stay at the facility. Resident #46 was interviewed on 1/25/24 at 10:54 a.m. Resident #46 said he said he did not know what was going on when he admitted . He said he had health issues that led to some confusion when he was admitted to the facility. He said he signed paperwork but he was not sure what he signed. He said he did not know what arbitration was. He said he wanted to know he signed something he was not familiar with and to be able to change his mind. Resident #46 said he signed what the facility gave him to sign. The resident said he did not read anything he signed. He said he did not read or write well. Resident #22 was interviewed on 1/25/24 at 6:37 p.m. Resident #22 said she did know what an arbitration agreement was. She said she did not remember anyone explaining the agreement to her or that she had 90 days to cancel it. She said the facility could have told her when she was admitted but she was so emotional during that time, she did not remember signing it. Resident #42 was interviewed on 1/25/24 at 7:25 p.m. He said he did not know what an arbitration agreement was and did not think he signed the agreement. He said he did not remember anything explained about the 90 days. VI. Facility follow up The NHA and the corporate consultant (CC) were interviewed on 1/25/23 at 7:08 p.m. The NHA said the facility was changing the form to help improve the comprehension of the agreement and staff would be educated on the arbitration process. The CC said training would be provided throughout the corporation to nursing home administrators and the family advisors on the arbitration agreement. The CC said the facility would review all the current arbitration agreements and review the agreement with the residents and/or resident representatives.

Oct 2022 23 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to ensure staff were prepared for a potential threat of fire. The lack of preparation resulted in residents scared, anxious, removed from their beds at night, placed outside in parking lots with smoke filled air, and for some, without supplemental oxygen as needed during a facility wide evacuation on 9/23/22. The lack in preparation for a potential emergent threat, included the failure to have a complete and thorough emergency preparedness training program, specifically fire training, to identify when residents should be evacuated and when residents should be placed behind closed fire doors. According to interviews with management the staff panicked and overreacted. The absence of adequate training, resulted in a chaotic situation as identified by a resident family member, referring to the evacuation on 9/23/22. The facility was also unprepared to handle residents' supplemental oxygen needs in an event of an emergency. The facility failed to establish an efficient oxygen management system in place to ensure residents who required supplemental oxygen and/or had chronic obstructive pulmonary disease (COPD) with a need for continuous oxygen, had it available to them as required and on demand as needed. The facility did not routinely fill portable oxygen tanks or effectively monitor the oxygen levels in the portable tanks. Further investigation identified the portable oxygen tanks were difficult to fill, time consuming, and the liquid oxygen would often freeze up during the filling of the tanks. These failures resulted in some of the residents who needed the supplement oxygen, did not have it available to them for a for extended amount of time during the evacuation on 9/23/22, causing residents unnecessary physical and mental stress, specifically Resident #7. Resident #7 had a physician's order for the continuous use of oxygen related to acute and chronic respiratory failure with hypoxia. The resident also had a long history of COPD with acute exacerbation. (Cross-reference F695 respiratory care.) During the 9/23/22 evacuation, Resident #7, along with three other residents (Resident #20, #23, and #26) were assisted outside of the facility without means to obtain supplemental oxygen timely. Resident #7 had a portable oxygen tank attached to her walker during the evacuation; however, the portable oxygen tank was empty. The above identified accident hazard failures created the likelihood of a serious adverse outcome for all of the residents in the facility. Furthermore, Resident #12 was admitted on [DATE] to the facility. She had severe cognitive impairment with a score of two out of 15 for the brief interview of mental status. The resident was identified as a fall risk as she had falls prior to entering the facility. The intervention which was put into place was encouraged to use the call light. The resident experienced the first fall on 7/8/22 and the bed was put into the low position and fall mat, she fell a second time on 7/9/22 which resulted in a fractured hip. The facility failed to timely initiate fall precautions for Resident #12. These failures contributed to her falling and fracturing her hip. Resident #1 had an unwitnessed fall on 9/28/22. Resident #1 was picked up off the floor and placed in her wheelchair before she was appropriately assessed. A registered nurse was not contacted or present for the resident's assessment for injury prior to the resident being moved by the licensed practical nurse and the certified nurse aide. Resident #30 had a history of falls and diagnosis of Parkinson's disease. He had two falls in just over a week apart. Resident #30 fell on 9/11/22 and again on 9/19/22. The fall documentation identified contributing factors to the falls included unsteadiness on his feet, weakness, and increased shuffling of gait. The last fall care planned intervention was on 4/25/22. The care plan was not updated to reflect new interventions to prevent potential future falls based on the assessment of the 9/11/22 and 9/19/22 falls. In addition, the facility failed to: -Consistently follow fall precautions and implement effective fall interventions for Resident #34; and, -Ensure the staff utilized two staff when utilizing a mechanical lift for Resident #3. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy A lack of a system in place to ensure the staff followed the facility emergency plan regarding evacuation procedures for potential fire. Staff reported and demonstrated a lack of training with the emergency preparedness plan which had a high likelihood to result in an accident hazard. On the night of 9/23/22, smoke entered the facility from outside of the facility. The source of smoke was off the property and fire was not an immediate threat to the facility. The staff, unprepared to handle an emergent situation, and not able to locate the fire or determine if the fire was inside the facility or outside the facility, contacted the director of nursing and reported fire was everywhere. The director of nursing instructed the staff to evacuate outside. As a result, residents were unnecessarily evacuated with several residents reporting they were scared and felt increased anxiety. One resident was reported as crying. At least four residents who required oxygen were evacuated without it. The cold air and smoke in the air with the lack of oxygen made breathing difficult. B. Imposition of Immediate Jeopardy Based on interviews and record review, which revealed policies and protocols were not followed to ensure staff were prepared for a potential threat of fire with comprehensive fire training and lack of training on required medical equipment, the nursing home administrator (NHA) was informed on 9/29/22 at 3:32 p.m. the facility failures above created the likelihood of serious harm for all of the residents in the facility if the failures were not corrected immediately. C. Facility plan to remove immediate jeopardy On 10/4/22 at 10:18 a.m. the facility submitted the final plan to remove immediate jeopardy. The plan read: 1. Staff education All staff scheduled to work beginning 9/29/22 were educated on the community's emergency plan to include fire procedures which includes RACE (rescue, alarm, contain, evacuate) and PASS (pull, aim, squeeze, sweep), evacuation procedures, central command, who directs the emergency and essential medical supplies and devices needed to ensure the safety of the residents. The training also included, who is central command during normal business hours and after hours, central command will call 911 and initiate the call to management, evacuation decision is in coordination of central command and first responders/fire department to determine if evacuation is needed based on each situation. The executive director was educated by the regional director of operations on 9/29/22, the maintenance director was educated by the regional environmental director on 9/29/22. The regional director of operations and the regional environmental director provided verbal reeducation after the evacuation on Friday 9/23/22 to the ED (executive director). Staff training included: -Fire alarm; -How to check the fire panel to ensure it is functioning properly and clearly identifies where the fire is located; -When to evacuate commanded by the appointed designee comand control who is the East station licensed nurse and first responders. The east station assumes command control until the highest ranking manager arrives. The East station licensed nurses have been educated on their duties as a command control; and, -When to be contained in the facility. Education was provided to all staff who were currently working in the facility, was provided in person, and written education was provided to all staff that were working in the community at the time the IJ was placed on 9/29/22 by executive director (ED) and maintenance director (MTD). Education was provided as follows: -On 9/29/22 at 5:30 p.m., at 6:40 p.m. to all staff present in the facility by the executive director. -On 9/29/22 at 10:00 p.m. prior to staff starting shift by the maintenance director. -On 9/30/22 at 5:30 a.m., 6:00 a.m., 7:00 a.m., 7:40 a.m. prior to staff starting shift by the executive director. -On 9/30/22 at 10:00 a.m. and 1:00 p.m. for staff not on duty that were called to come in for education and staff coming on shift prior to their shift by the maintenance director. -On 9/30/22 at 5:45pm for staff on duty at the time of second immediacy plan reeducation was provided by executive director. -On 9/30/22 at 6:40 p.m. prior to staff starting shift by executive director. -On 10/1/22 at 5:45 a.m., 6:05 a.m., 6:20 a.m., 6:40 a.m, 7:00 a.m., 1:00 p.m. prior to staff starting shift by executive director. -On 10/2/22 at 9:00 a.m., 2:00 p.m., by executive director. -On 10/2/22 at 5:45 p.m., 10:00 p.m. prior to starting shift by the maintenance director. -On 10/3/22 at 6:00 am prior to the starting shift by executive director. All staff that have not been educated were notified by their department managers to attend training sessions scheduled for 9/30/22 at 10:00 a.m. or 1:00 p.m. Staff who have not been trained, will not work their shift until completed the training from the ED or MTD. Newly hired staff will receive training on the day of hire during their orientation. Education attendance sheets will be reconciled by the Executive Director to ensure all staff had been trained on emergency preparedness. Education attendance reconciled as of today 10/3/22, education is continuing to ensure all staff are educated. 2. Education will be monitored for effectiveness Fire drill will be conducted on each shift by the maintenance director on Monday 10/3/22. -Fire drill conducted on 9/30/22 at 3:30pm; -Fire drills will be held monthly on different shifts, which equates to quarterly per shift; and, -Safety team who consists of maintenance director, business office manager, medical records director, director of nursing, head chef and executive director will evaluate at monthly safety meetings the drill response and staff competencies during drill to identify opportunities for improvement. 3. Communication during a emergency The facility will have walkie talkies available for use. They will be in effect on 10/7/22. The maintenance director is responsible to provide training and to ensure the walkie talkies are kept ready to use. The facility utilizes the resident report sheets and daily schedules to ensure all are accounted for by the incident command control at the time. 4. Competencies After the staff have been trained on the emergency preparedness, a test is administered on what was learned, and also return demonstrations and asking situational questions are asked to the staff by executive director or maintenance director. The interdisciplinary team (IDT) will review the drills (which validates individual competencies) for opportunities of improvement and continued education on opportunities identified. Drill checklist will be reviewed at the huddle right after the fire drill, and will be completed by the Maintenance Director. These reviews will be as follows: Drill Checklist Were fire alarms and strobes sounded? Were all exit doors checked to see if they released while in alarm, and did they release from magnets properly? Were residents moved to safety? Length of time from start of alarm to residents being secured? Were all resident room doors closed? Were all office and dining room doors closed? Was response time sufficient? Was the fire department notified? Was the fire properly announced? How long did it take to announce the fire? Were safety standards met? ie: no walking through smoke doors without fire extinguishers, swamp coolers turned off? How many staff members responded with fire extinguishers? 5. Procedure for any outside fires near the property will be to follow any guidance provided to us by the local fire department. 6. Medical supplies-oxygen Each resident has a portable oxygen tank assigned to them. The portable oxygen tank: -To be filled by night shift staff before each resident arises in the morning; -Oxygen portable tanks will be checked before and after each meal and filled if indicated; -Oxygen portable tanks will be checked at bedtime and filled if indicated; -Oxygen portable tanks will be checked PRN at resident request and filled if indicated; and, -The facility has a list of residents who require oxygen. Compliance will be monitored with random checks during meal times and nursing/administrative rounds five days a week. The director of nursing (DON)/NHA will designate staff members to complete random checks and any issues identified will be reported immediately to DON/NHA and re-educated as indicated. Any issues identified are addressed with retraining and education on the spot. C. Removal of immediate jeopardy On 10/4/22 at 11:00 p.m., the NHA and the DON were notified the immediate jeopardy was removed at 10:18 a.m., based on the plan above. However, deficient practice remained at an E level, a pattern with the potential for more than minimal harm. II. Facility policy The If You Discover A Fire In Your Area policy and procedure, dated June 2012, was provided by the nursing home administrator (NHA) on 10/4/22 at 8:49 a.m. The policy read in pertinent part: Remove anyone in the room while calling out 'Code red, location .' for assistance. Close the door to the fire room and any room connecting doors. Activate the fire alarm and make overhead page announcements of the fire location. Close all remaining doors and windows in the fire zone, placing residents into rooms. Evacuate remaining rooms in the smoke compartment if directed to do so by the person in charge. The Charge Nurse fire procedures were provided on 10/4/22 at 8:49 a.m. According to the procedures, the charge nurse was to initiate the following steps in a fire was on their unit they needed to ensure: -The fire room had been evacuated; -The door to the fire room had been closed and marked; -Fire alarm had been activated and a page announcement of the fire location made; -All residents had been removed from the corridor with doors and windows closed; and, -All equipment had been removed from the hallway. The charge nurse fire procedures directed the charge nurse to make a decision regarding further evacuation by using the following guidelines: -If the fire has been extinguished, no further evacuation is necessary. Instruct the staff to reassure residents while awaiting arrival of the fire department; -If the corridor smoke conditions would not be tolerable for residents, do not evacuate. Inform the fire department of smoke concerns upon their arrival. -If the fire had not been extinguished and the corridor conditions were tolerable begin evacuation by moving the residents from the fire compartment to the adjacent side of the fire/smoke doors as identified in the evacuation diagram. Instruct staff to evacuate rooms adjacent to the fire room first, followed by the room opposite of the fire room. The remaining rooms in the compartment should then be evacuated. -Mark the door to the room with a pillow in front of the door to indicate that the room had been evacuated. For this purpose the orange tape is stored in each medication room. -Account for residents and staff once all are relocated. Be prepared to report results to the control station. According to the charge nurse fire procedures, the charge nurse was responsible for: -Directing appropriate staff to respond to the fire area; -Directing remaining staff in securing unit by moving residents into rooms, closing windows and doors, and clearing corridors; -Directing staff to make rapid rounds, checking on and reassuring residents Once the unit was secured; - Directing staff in the preparation of receiving residents by clearing space for the arriving residents from the evacuated unit. Position one staff member at the entrance of the unit to direct staff arriving with evacuated residents to the appropriate areas of the receiving unit. -Ensure initial care of residents who have been evacuated if applicable. The charge nurse fire procedures identified the East nurses station charge nurse with activation of the fire alarm was to: -Check the fire alarm panel to determine location of alarm; -Make overhead page announcement of alarm location; and, -Place a backup call to the fire department (911). The Action Plan procedure pertaining to facility evacuations, dated July 2017, was provided by the NHA on 10/4/22 at 8:49 a.m. According to the policy, to evacuate the full building evacuation plan, the decision to evacuate should be made with input from emergency service agencies. The action plan identified agencies to be notified included emergency services (911), Delta County/ State Office of Emergency Management, and the Colorado Department of Public Health and Environment. III. Events of 9/23/22 1. Electrical panel fire A. Observations On 9/26/22 at 11:47 a.m. the hall lights went out of the B hall. At 11:49 a.m. the door alarm started to sound. A staff member walked down the hall towards the door and said the breaker was not working. The activity director (AD) following the staff member said it was not working last night either (9/25/22). B. Staff interview Licensed practical nurse (LPN) #3 was interviewed on 9/26/22 at 1:56 p.m. The LPN said the morning of 9/26/22 she was conducting a fire watch around the facility because the fire panel was not working again. She said the panel has now been fixed and she was no longer conducting a fire watch. The LPN said during the past weekend someone did a temporary fix on the panel and it was in working order so she did not conduct a fire watch over the weekend. The NHA was interviewed on 9/26/22 at 2:55 p.m. The NHA said on the morning of 9/23/22, the breaker to the electrical panel became too hot and wires were melted. An electrician was contacted and was able to temporarily repair the system but determined a new breaker had to be installed. She said the breaker was not in stock and had to be ordered for a 9/26/22 arrival and installation. She said some of the alarm systems had to be turned off momentarily during the installation. The maintenance director (MTD) was interviewed on 9/29/22 at 2:37 p.m. The MTD said the facility was old and recently had an electrical fire in the panel on the morning of 9/23/22. The electrician temporarily fixed it on 9/23/22. The electrical technician completed the repair process on 9/26/22 and 9/27/22 with new components. He said the fire panel was officially fixed on 9/27/22. The MTD said he had no issues with the panel before 9/23/22. He said the electric company said the breaker had burned up and fused itself. The electrical technician was going to send the breaker to a specialist to see why the breaker burned up. 2. Facility evacuation in response to a potential fire A. Staff interviews The DON was interviewed on 9/26/22 at 3:04 p.m. with the NHA. She said she received a call from a certified nurse aide (CNA) that there was a fire somewhere in the building. She said she saw smoking outside the backdoor. The DON said LPN #1 was the charge nurse on 9/23/22. The DON said by the time she arrived, the residents were evacuated. The fire department conducted three sweeps of the building before it was all clear. She said the alarm sounded just before 9:00 p.m. and residents were back inside and in bed by 11:00 p.m. She said residents were provided blankets and separated in small groups to be supervised by staff. The NHA and DON said they felt staff did well during the evacuation but should have sheltered the residents in place so they would educate the staff and review the policy with the staff. LPN #1 was interviewed on 9/28/22 at 7:45 p.m. The LPN said both her and LPN #4 were considered the charge nurses at the time of the evacuation on 9/23/22. The LPN said she was responsible for the west side of the facility and LPN #4 was responsible for the east side. She said a CNA told her that staff could smell smoke on the east side of the facility and staff saw smoke coming from the basement. The LPN said the staff believed the smoke was coming from the boiler area. LPN #1 said smoke alarms were not triggered/sounding at the time. She said earlier on the day of 9/23/22, fuses had burned and assumed it was smoke from the burned fuses. LPN #1 said LPN #4 decided to evacuate her residents on the east side outside, so she started evacuating her residents on the west side. The residents were divided up in two parking lots on different sides of the facility. She said the NHA was called but the residents were already being evacuated outside. She said the maintenance director (MTD) was called. She said she thought CNA #1 called 911 and then emergency vehicles arrived. CNA #1 was interviewed on 9/28/22 at 8:20 p.m. CNA #1 said she said the night of the evacuation she smelled smoke and saw thick smoke from the floor to the middle of the hallway. The CNA said she told the other staff they had to go outside. The other CNAs said they also saw smoke from the basement. CNA #1 said LPN #4 told the staff they were to evacuate the residents outside. The CNA said one other CNAs called 911. She said the other staff helped residents outside while she stayed with the residents who wandered until she could get more assistance. She said the air conditioner was drawing smoke inside the facility. She said the night of 9/23/22 she thought the facility had to evacuate because there were residents who had chronic obstructive pulmonary disease (COPD). She said the alarm was going off and smoke was already in the facility so they evacuated. The director of nursing (DON) was interviewed on 9/29/22 at 11:03 a.m. The DON said she was contacted by staff on the night of 9/23/22 and was told there was a fire and the building and smoke was everywhere. The DON said that she had instructed the staff to evacuate the entire facility if there was fire and smoke inside and bring them to the parking lot. She directed the staff to evacuate the residents first then if possible go back inside the building to get oxygen and medication carts.The DON said she asked if the fire panel was checked and where the location of the fire was. She said they checked the fire panel but could not hear where the location of the fire was because she was in a bad phone service area. The DON said when she arrived at the facility at approximately 9:25 p.m. She said the smoke was not visible. The DON said if there was smoke outside it would not have been a good idea to take them outside. She said the smoke could make the residents sick. She said NHA was in charge of the facility and would normally be the one to make the call to evacuate. She said staff should have contained the residents to one area in the facility away from any identified smoke. She said if it happened again, staff should move residents to the other side of the building. CNA #5 was interviewed on 9/30/22 at 4:30 p.m. CNA #5 said he was present during the evacuation on 9/23/22. He said that he did not see smoke in the building, but he could smell a smoke odor in the building, but not too extreme. He said earlier in the day the circuit panel was not working properly, so he and CNA #9 went to look at the fire box outside of the building. He said while they were standing in the dark CNA #9 pointed toward the stairs and said she saw smoke. He said things went quick and they started to evacuate the building, he was not sure who had made the decision to evacuate. He said he was the muscle of the group, and he began to lift residents out of bed into wheelchairs, so the others could assist them outside. He said he remembered the oxygen portable for Resident #31 but that it was probably not a full tank. He said when outside, the residents had blankets and they waited for the fire department to direct them what to do. He said communication was hard, as he had no means to know what was happening outside, as he was inside. He said walkie talkies or some form of communication would help a lot. He said the NHA interviewed him last night about the evacuation, not any other time. CNA #9 was interviewed on 10/3/22 at 10:04 a.m. She said she started to smell smoke in the facility and went to the east side of the facility where LPN #4 was. She said she asked the LPN if she smelled smoke and they both proceeded to look for where it could be coming from. She said they checked near the electric panel and the boiler but the door was not hot. LPN #4 told CNA #9 to pull the fire alarm, shut all windows and doors and start evacuating. She said staff proceeded to evacuate all the walking residents, then the wheelchair resident and finished the evacuation with bed bound residents. The NHA was interviewed on 10/5/22 at 4:24 p.m. The NHA said she has not had a post incident review on the evacuation yet to review all that happened during the night of 9/23/22. She said she did not do the review because surveyors entered the facility on 9/26/22, the same day they were going to do the post-incident review. The NHA said the DON was told the building was on fire so they evacuated. She said she spoke with staff on the night of 9/23/22 while she was driving to the facility but was in a bad service area during the call and was not sure where the fire was located that prompted the evacuation. She said the facility had since discussed what to do when staff smell smoke, whether the source was inside the facility or coming in from the outside. She said the facility has also discussed when to evacuate the residents and when to contain the residents in their room. She said during the discussions she identified the failures as lack of training and fear. She said the facility had since learned the staff needed more fire training and they overreacted which inturn prompted the facility evacuation. B. Record review 1. Fire department report The fire chief's incident narrative and 9/23/22 incident report was provided by the NHA on 10/4/22 at 3:20 p.m. The 9/23/22 incident report identified the fire alarm record time as 9:05 p.m. The fire department arrived at 9:17 p.m. The fire department cleared the facility at 10:23 p.m. The fire chief's incident narrative identified events observed and conducted by the fire department at the facility on 9/23/22. The narrative read: Paged to (facility) for a report of a fire in the basement. Upon arrival we found no fire at the facility. There was smoke in the air from a nearby fire that we were unable to locate. We cleared the entire building using a TIC (thermal imaging camera). We were unable to locate any spot fires or heat. Staff had informed us that there had been a fire earlier in the electrical panel outside at around 11:00 a.m. They had called an electrician to fix the panel but didn't have time to properly do the job and did a fix that 'would get them through the weekend.' I advised the head of staff to contact the electrician and have them come out tonight (9/23/22) and look at the wiring within the box, as the previous fire had compromised multiple wires inside. We were unable to reset the alarm panel and advised the supervisor to do a firewatch throughout the night. They were going to try to reset the panel themselves. They evacuated all the residents of the facility during our arrival. They were allowed to enter the home once we were unable to locate any fire. 2. 9/23/22 incident notes The 9/23/22 incident notes with a staff attendance record were provided by the NHA on 10/3/22 at 10:40 a.m. The notes identified the fire panel was triggering an error message and could not be reset so the panel was taken offline. The notes also provided a timeline when management was contacted and when they arrived at the facility on 9/23/22. -At 8:58 p.m. the DON was called by staff; -At 8:59 p.m. the MTD was called; -At 9:00 p.m. the NHA was called; -At 9:30 p.m. the DON arrived onsite; and, -At 9:58 p.m. the NHA arrived onsite. IV. Resident impact A. Resident and family interviews Resident #7 was interviewed on 9/26/22 at 9:47 a.m. The resident said she needed to be on oxygen at all times because of her COPD. She said her portable oxygen was usually empty and staff needed to fill it up (cross-reference F695 for respiratory needs). The resident stated staff often did not make sure her portable was filled at night which became a problem on 9/23/22. Resident #7 said she was assisted outside during a facility evacuation on 9/23/22 after she was told by staff they smelled smoke in the facility. She had her portable oxygen tank attached to her walker but the oxygen tank was empty. Resident #7 said the cold air outside made it even harder to breathe. She said she did not receive oxygen until the paramedics arrived and provided it to her. Resident #7 said she was outside for 45 minutes to an hour, much of the time she was outside without oxygen. She said she has had COPD for years and knows when her oxygen saturation levels drop. She said during the evacuation and without continuous oxygen, she became light headed and started seeing fire works. The resident said she normally had some anxiety and she became very anxious without the needed oxygen during the evacuation. Resident #35 was interviewed with her family on 9/26/22 at 12:09 p.m. The family member said an electrical panel burned out on 9/23/22 during the day. Resident #35 said on the night of 9/23/22, the fire alarm sounded and staff slid her out of bed, placed into a wheelchair, and was taken outside. The resident said she was outside for about an hour. Resident #3 was interviewed on 9/27/22 at 9:34 a.m. The resident said the facility evacuated from the building on the previous Friday (9/23/22). He said he was in bed for the night when the CNA came in and told him they needed to evacuate the building. He said he was manually lifted out of bed with two certified nurse aides. He said he received a skin tear on his right elbow as they got him out of bed. He said he was usually transferred with a mechanical lift. He said it all went so fast. The resident's right elbow had a bandage on it. Resident #20 was interviewed on 9/28/22 at 11:45 a.m. The resident said that the facility evacuated from the building on Friday 9/23/22. She said that she was awoken from sleep and told that they needed to get her out of the building as they were evacuating the facility. She said that when she was assisted outside, she was taken outside without her oxygen. She said that she was having trouble breathing. She said the fire department provided her with oxygen 45 minutes later. Resident #20 was interviewed a second time on 9/28/22 at 1:35 p.m. The resident said when she was awoken from bed, she was told by the two CNAs to jump from her bed. She said she could not and that she was scared. She said the CNAs said they would catch her. She said the bed needed to be lowered, then she would have been able to step off of the bed easier. She said she had to jump from the bed, which was approximately ten inches from the floor. Resident #23 was interviewed again on 9/29/22 at 12:30 p.m. The resident said that on Friday (9/23/22) he was informed that the facility had to evacuate. He said he had been sleeping and he said he grabbed his hat and nothing else. He said he left the facility without his oxygen. He said he could not recall the length of time he went without his oxygen. He said without his oxygen he had grasped for his breath. He could not recall when he received oxygen. He said he was told someone was burning trash outside and the air conditioning

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Incontinence Care (Tag F0690)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#11 and #16) of two reviewed for catheter care out of three residents with catheters. The facility failed to ensure Resident #11's urinary catheter down drain bag was kept from dragging on the floor and the urinary catheter bag was kept below the bladder. There were no physician orders on how to clean the area around the suprapubic catheter site. Due to the facility's failures, Resident # 11 suprapubic urinary catheter line to drag on the floor and no order to cleanse the site, contributed to an infection as evidenced by the purulent (pus) drainage from the catheter exit site which caused pain to the resident. In addition, the facility failed to: -Ensure Resident #16 was provided catheter care assistance with emptying her catheter bag and monitoring catheter fluid level to ensure timely empting of her catheter bag; and, -Ensure Resident #16 had proper placement of her catheter bag. Findings include: I. Facility policy and procedure The Catheter Care, Urinary policy and procedure, revised September 2014, was provided by the director of nurses (DON) on 10/4/22 at 10:30 a.m. With instructions, be sure the catheter tubing and drainage bag are kept off the floor. Along with The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. II. Resident #11 A. Resident status Resident #11, older than age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO) diagnoses included retention of urine, unspecified and urinary tract infection, site not specified. The7/12/22 minimum data set (MDS) assessment showed the resident had minimal cognitive impairment with a score of 13 out of 15 on the brief interview for mental status (BIMS). The MDS coded the resident as requiring no assistance with activities of daily living. The resident had a catheter. The MDS incorrectly coded the resident as always continent. B. Observations On 9/26/22 at 12:50 p.m. the resident was walking down the hall. The resident's catheter tubing was dragging on the floor. The catheter bag hung on the walker. On 9/28/22 at 8:05 a.m. the resident's suprapubic urinary catheter tubing was dragging on the floor as she walked in the hallway. On 10/3/22 at 10:37 a.m. the resident's suprapubic catheter insertion site was observed with the licensed practical nurse (LPN) #5. The insertion site was noted with greenish, thick colored drainage, the resident denied pain at this time. LPN #5 said the previous shift nurse reported that the site didn't look good. She said the insertion site had purulent drainage. There was no documentation noted in the chart of the findings and there was a failure to notify the doctor of the change of the resident's condition. LPN #5 reported that the leg drain bag should not be left on the resident's leg throughout the night. On 10/4/22 at 3:25 p.m. the resident's suprapubic catheter insertion site was observed with the LPN #5. The insertion site had thick, cream colored drainage. LPN #5 obtained a culture of the drainage, afterwards wiping the area with a tissue and cleaning with one betadine (antiseptic) swab, not allowing the betadine to dry, then placing resident's undergarment over the area, no dressing was placed over site. During the cleaning with the betadine swab, the resident pulled back and winced in pain. The resident said she had pain around the site. C. Record review The September 2022 CPO, a physician order was entered on 4/1/22, stating: cleanse stoma site twice daily, check skin for redness or drainage, and notify MD (medical doctor) of skin changes from baseline. The September 2022 treatment administration record (TAR) revealed, starting on 4/2/22, the stoma site was to be cleaned daily and as needed. Discontinue date of 9/23/22. On 9/23/22 a new treatment was added to cleanse stoma twice daily. -There was documentation that stoma site was being cleaned, but no documentation of how it was being cleaned. The care plan initiated on 4/1/22 identified the resident had impaired urinary elimination pattern and the need for a suprapubic catheter. Some days the resident may choose to use a leg bag and other days a larger drainage bag; their preference. -There was no documentation in the resident's chart showing that she was offered this preference and what the preference was daily. The goal added on 9/29/22 (during the survey), for the resident to have a decreased risk for developing complications associated with catheter usage such as a urinary tract infection. The care plan documented that the suprapubic catheter should maintain a position of the catheter bag and tubing below the level of the bladder. Interventions were added on 9/30/22 (during the survey) to the care plan to ask the resident if a leg bag or down drain foley catheter bag was to be used based on their preference, along with observing and reporting for s/s of an infection-strong odor, cloudy, and urgency. LPN #5 faxed the primary doctor the change of the resident's condition on 10/3/22, there was no documentation noted in the chart of this action. She reported that after no response she called at 2:00 p.m. and 3:30 p.m. both attempts went to an answering machine. There was no documentation of this in the chart. The resident had a urine culture lab test, collected on 10/4/22 at 3:12 p.m. the preliminary results on 10/5/22 9:56 a.m. noting an organism present: presumptive E. coli greater than 100,000 CFU/ml. D. Staff interviews Registered nurse (RN) #1 was interviewed on 9/29/22 at 10:30 a.m. RN #1 said the catheter tubing should not drag on the floor, as it could cause an infection. She said she would assess to determine if a leg bag could be used. RN #1 was interviewed a second time on 9/29/22 at 11:06 a.m. RN #1 said the resident agreed to try a leg bag. She said the leg bag was in place. Certified nurse aide (CNA) #3 was interviewed on 10/3/22 10:13 a.m. CNA #3 said the resident was using the leg bag, however, the leg bag was not being changed at night for a larger drain bag and it was staying on the resident's leg throughout the night, which could result in the leg bag not being below the bladder. LPN #5 was interviewed on 10/3/22 at 10:37 a.m. LPN #5 said the leg drain bag should not be left on the resident's leg throughout the night. LPN #5 confirmed nothing was documented in the resident's medical record and that she had forgotten. LPN #5 said she faxed the medical director the change of the resident's condition. She said after no response she called at 2:00 p.m. and 3:30 p.m. both attempts went to an answering machine. -However, there was no documentation of this in the resident's chart. LPN #5 was interviewed again on 10/4/22 at 10:12 a.m. She reported that she had forgotten to document notifying the physician. She reported that the nursing staff have been wiping the drainage from the site with a tissue, then cleaning the area around the suprapubic catheter with betadine. -However, no physician order was found for the betadine. She reported that the drainage is white in color and that the resident reported redness and pain at the site. LPN #5 said that she had forgotten to document any information about the infection. The DON was interviewed on 10/4/22 at 10:31 a.m. The DON said that the on-call doctor should have been called on 10/3/22 when the facility was unable to reach the resident's doctor. She said the leg bag should not have been left on the resident's leg through the night, it should have been changed to a larger drain bag hanging below the resident's bladder. She said that she would educate the nursing staff. III. Resident #16 A. Resident status Resident #16, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses included personal history of transient ischemic attack (TIA) and cerebral infarction (stroke), chronic pain, urinary incontinence, difficulty walking, unsteadiness of feet, cognitive communication deficit, overactive bladder and need for assistance with personal care. According to the 7/28/22 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. The MDS assessment indicated the resident was independent in activities of daily living (ADLs). The MDS assessment identified the resident had a catheter. B. Resident interview and observation Resident #16 was interviewed on 9/27/22 at 9:04 a.m. She said staff did not assist her with the emptying of her bag. Resident #16 said they were often busy taking care of other residents. She said she had watched how they emptied her catheter bag before and then trained herself. The catheter bag was observed laying on the floor next to the resident's feet as she sat in her reclining chair in her room. The catheter bag was not hanging on her walker or another device to keep it off the floor and below her waist. The bag was not covered by a protective cover as it laid on the floor. The catheter bag was almost completely full with fluid. Resident #16 was observed on 9/29/22 at 9:26 a.m. Her catheter bag was attached to her walker. There was not a cover over her bag. The bag was more than half way full. The resident said she would have to empty the catheter bag in a little while. Resident #16 was interviewed on 10/4/22 at 3:20 p.m. She said it was hard to remember when to empty her catheter bag and when to check if the catheter bag needs to be emptied. She said she would like for more help from the staff to monitor her catheter and assist her in ensuring the bag was emptied timely. She said she was worried it might become too full and back up causing an infection. C. Record review The certified nurse aide (CNA) tasks sheet read Resident (#16) has a suprapubic catheter. Position bag and tubing below the level of the bladder. The CPO, initiated 4/6/22, directed staff to maintain Resident #16's suprapubic catheter site and clean as needed. The urinary catheter/UTI care plan last revised on 4/19/22, indicated the resident had an impaired urinary elimination pattern and continuous incontinence of urine. According to the care plan, the resident should have a decreased risk for developing complications associated with catheter usage such as urinary tract infections (UTIs). The care plan directed staff to provide Resident #16 catheter care q (every) shift, and as needed. According to the care plan staff should also ensure her foley strap was in place, not pulling off the catheter, and the foley was properly draining. The CPO for Amoxicillin (antibiotic) at 500 milligrams (mg) capsule, started 10/2/22, was ordered for the resident. D. Staff interviews CNA #1 was interviewed on 9/28/22 at 8:15 p.m. The CNA said she was new to the facility but has been working with Resident #16. She said staff told her that Resident #16 emptied her own catheter bag. She said Resident #16 needs frequent reminders to empty it. She said she has seen the resident's bag sometimes full because the resident has not emptied it yet. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 10/4/22 at 3:05 p.m. The DON said all residents needed assistance with catheter care, including the emptying of the catheter bag and the monitoring of the fluid level. The NHA said some residents have been evaluated by therapy to determine if the resident could provide catheter care management such as emptying catheter bags themselves. She said the CNAs routinely monitor residents' catheter fluid level and would document the amount of fluid bag before it was emptied. The NHA reviewed Resident #16 medical record. The NHA said Resident #16 had not been evaluated or approved to empty her own catheter bag. She said the CNAs have not been charting the amount of urine output emptied from the resident's catheter bag. The NHA said staff should have been assisting Resident #16 with emptying her catheter bag and monitoring the resident's fluid level collected from her catheter. The NHA said staff should also ensure the catheter bag was properly positioned when the resident was sitting in her reclining chair in her room. The NHA said the bag should have been hung below the resident's bladder and never placed on the floor. The DON and NHA acknowledged placing the catheter bag directly on the floor could create a potential infection control concern. The NHA said staff needed to be responsible for the emptying and monitoring of the resident's catheter. She said would educate the staff to empty the resident's catheter bag, monitor and document the fluid level/output, and proper placement of the catheter bag when the resident was sitting in her room. Registered nurse (RN) #1 was interviewed on 10/5/22 at 3:39 p.m. She said Resident #16 had a new UTI, identified on 10/2/22. The RN said Resident #16 was now on antibiotics related to a UTI.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #34 A. Resident status Resident #34, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician order, diagnoses included Alzheimer's disease, depression, and anxiety. The 6/5/22 MDS assessment revealed the resident had had severe cognitive impairment with a score of two out of 15 on the brief interview for mental status. The resident was independent in walking and required limited assistance with all activities of daily living. It indicated the resident did not have a swallowing disorder. No dental abnormalities were noted. B. Observations 9/26/22 -8:30 a.m., the resident was at the dining room table awaiting her meal. The resident had a pitcher of water and a 120 milliliter (ml) cup on the resident table. However, she did not receive assistance to pour the water. -At 12:44 p.m., the resident received a total of 240 ml fluids (ice tea & water) however, drank approximately 120 cc tea. She did not consume or receive encouragement to drink the water. 9/27/22 -At 8:30 a.m., the resident drank coffee, approximately 50 ml of fluid. -At 12:30 p.m., the resident drank approximately 60 ml of ice tea. She was not encouraged to drink the remaining of the 120 ml of tea and did not have a glass of water. 9/28/22 At 12:30 p.m., the resident was served 120 ml of ice tea, however, she drank approximately 40 ml of the tea. She was not poured any water and received no encouragement to drink the remaining ice tea. 10/3/22 -At 8:18 a.m., the resident was served 120 ml of coffee, and although she was offered a second cup, she declined. She did not have any water poured from the water pitcher on the table. C. Record review The care plan last updated on 9/13/22 identified the resident was at risk for inability to maintain her nutrition. Pertinent interventions included, monitor intake and record each meal. -The care plan failed to include the amount of fluid the resident required each day. According to the RD interview, the resident did not have a nutritional assessment to indicate her daily fluid needs (see below). The hydration record for September 2022 was reviewed. The resident drank on average 240 ml at breakfast and 240 ml at afternoon meal. The dinner meal was not documented, only once at 100 ml. The snacks intake was not consistently entered with only 240 ml on five days. The observations and the documentation that the resident received less than 1500 ml a day (indicated by the RD, see below). D. Staff interview CNA#3 was interviewed on 10/2/22 at 4:40 p.m. The CNA said she assisted the resident to eat her food by showing her what was on her plate. She said she made conversation with the resident as she was eating, asking the resident what she liked to eat and if she liked to cook. She said the resident was more inclined to eat when she encouraged the resident. The RD was interviewed on 10/5/22 at 4:40 p.m. The RD reviewed the record and confirmed that a nutritional assessment had not been completed for Resident #34. The resident should have an assessment which documented the resident's fluid needs. She said that minimally the resident required 1500 ml, however, she preferred to calculate out what the resident's specific needs were. The RD said the resident should have the water poured while at the table and receive encouragement to eat and drink. Based on observations, record review and interviews, the facility failed to ensure three (#12, #28 and #34) of six out of 26 sample residents received the care and services necessary to meet their nutritional needs and to maintain their highest level of physical well being. Resident #12 was admitted on [DATE] with diagnoses of dementia and diabetes. The resident was placed in hospice care on 7/8/22. The resident was weighed on 5/3/22 and again on 5/4/22 at 2:33 p.m., at 100.7 pounds (lbs). Then the resident was not weighed again until 8/1/22 and she was 99.2 lbs, and the last recorded weight was on 9/2/22 at 9:58 a.m. at 92.5 lbs., a loss of 6.7 lbs, which was a 6.5% weight loss over one month considered significant. The resident did not receive a nutritional assessment either after admission or after she sustained a severe weight loss. An intervention of Ensure was recommended on 9/16/22, however the facility did not implement it, until 9/18/22. In addition, the facility failed to: -Address Resident #28's significant weight loss timely; -Follow RD interventions for Resident #28; -Perform a comprehensive nutritional assessment for Resident #34; and, -Assess and provide adequate hydration needs for Resident #34. Findings include: I. Resident #12 A. Resident status Resident #12, age [AGE], was admitted to the facility on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included type II diabetes mellitus with diabetic nephropathy, essential primary hypertension, acute and chronic respiratory failure with hypoxia, diabetic chronic kidney disease, dementia, and unspecified visual disturbances. The 5/3/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for a mental status (BIMS) score of two out of 15. She required extensive assistance of one person with bed mobility, dressing, eating, and personal hygiene. The resident was under hospice care. The resident was not coded for weight loss. B. Observations The resident was served her noon lunch tray on 9/28/22 at 12:39 p.m. The resident was offered meal assistance three times, however, the resident refused. However, throughout the meal, the resident was falling asleep, and no staff attempted to wake her up. She only consumed 25% of her meal. And no alternative meal was offered. C. Record review In the resident's care plan initiated 5/3/22, and revised on 7/8/22, a goal was established of not incurring weight loss, through a dietary consult for a nutritional regimen and ongoing monitoring. The care plan was not updated to include the recent weight loss or to include the interventions which were put into place. Resident #12's weights since admission: -On 5/3/22 the resident weighed 100.5 lbs. -On 5/4/22 the resident weighed 100.7 lbs. -On 8/1/22 the resident weighed 99.2 lbs. -On 9/2/22 the resident weighed 92.5 lbs., a loss of 6.7 lbs, which equals a 6.5% weight loss over one month. The September 2022 CPO revealed the following: -The resident was admitted into hospice 7/8/22. -Ordered 9/16/22, Ensure original formula two times a day, however no specific amount was included in the order. Review of the September 2022 medication administration record (MAR) showed the facility failed to start the Ensure timely as it was started on 9/18/22. The MAR also failed to show the facility was tracking the amount consumed by the resident. The medical record failed to show that a initial nutritional assessment or a change of condition related to the weight loss was completed for Resident #12. There were no quarterly assessments completed since admission. The meal and supplement intake records from September 2022 revealed the following: -The resident typically consumed 51-100% of breakfast, lunch and dinner. -The resident was provided with Ensure twice daily but there was no documentation of intake percentages/amount. B. Staff interviews The hospice registered nurse was interviewed on 10/3/22 at 11:05 a.m. He stated that the resident has a review in thirty days and that a recommendation of discharge from hospice would be discussed as the resident was not meeting the criteria for hospice care. The registered dietician (RD) was interviewed on 10/4/22 at 4:40 p.m. The RD said she began employment at the facility on 9/16/22, and that her first meeting with the skin and weight team would be 10/7/22. Normally, she would come once a week to the facility for the meeting but has not been to the last two meetings, due to the fact that the director of nurses (DON) and the nursing home administrator (NHA) have been working on the floor. When she began employment at the facility she noticed that weights were not being charted on a regular basis, she stated, not having monthly weights hinders me. She reported the process that after entering an intervention, there should be a weekly progress note following up on the intervention. The RD reviewed the medical record and confirmed the resident had experienced a significant weight loss of over 6% in a month's time. She said it was her assumption that an Ensure consumption amount was 240 milliliters (ml), and that the intake amount should be tracked. She said when a resident eats less than 50% of the meal, alternatives need to be offered, and that the documentation needs to be accurate. The DON was interviewed on 10/4/22 at 5:37 p.m. The DON said when the resident ate less than 50% of her meal, then an alternative meal needed to be offered. She reported that the staff needed to return to check on the resident even if she refused the help, in order to monitor what the resident was eating. Her expectation was for an accurate meal percentage documentation so that the resident was accurately evaluated on what she was eating. She said she was aware of the resident's severe weight loss. II. Resident #28 A. Resident status Resident #28, age [AGE], was admitted to the facility on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included unspecified dementia, altered mental status, depression, repeated falls, and muscle weakness. The 5/22/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15. The MDS coded the resident as requiring supervision with eating. B. Record review Weights since admission revealed the following: -On 5/9/22 the resident weighed 148.5 lbs -On 7/8/22 the resident weighed 135.5 lbs, a loss of 13 lbs., which equals an 8.75% weight loss -On 9/1/22 the resident weighed 134 lbs -On 10/3/22 the resident weighed 133 lbs The care plan dated 5/9/22 identified the resident as a potential for losing weight secondary to social isolation. With an intervention initiated on 5/25/22 of encouraging the resident to eat a healthy well-balanced meal. The September 2022 CPO revealed the following: -A physician order for the resident to be weighed daily for three days then weigh weekly for three weeks, ordered on 5/10/22. However, a review of the medical record showed the weights were not obtained according to the physician's order. -Fortified foods added on 9/8/22. The 8/25/22 nutrition note documented the resident was on a general diet order, mechanical soft texture, and thin liquids. Meal intakes have been between 76-100% of food and only approximately 240 ml of fluid intake. An estimation of daily nutrition needs for the resident were determined with the goal of 1550-1900 caloric intake and approximately 1600ml of fluid intake. Also, noted by the RD was a request for fortified foods at meals, and for updated weights. The 9/30/22 progress note documented due to the resident's significant weight loss since admission, she recommended fortified foods with every meal. C. Observation On 10/3/22 at 5:35 p.m., observed the resident's dinner tray being delivered to her room. On the tray were the following items: pasta, peas, pears and ice cream. No fortified foods were noted on the resident's tray. D. Staff interview The RD was interviewed on 10/4/22 at 4:40 p.m. She agreed that the dinner tray the resident received for 10/3/22 was not a fortified meal. She said examples of fortified foods were butter, brown sugar, mashed potatoes and heavy cream. The RD said that the facility did not have a specific menu for a fortified meal and that mashed potatoes should not be served with every lunch and dinner meal.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to promote resident dignity and respect one resident (#16) out of 12 residents reviewed for dignity out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #16 treated and spoken to in a dignified manner; and, -Ensure Resident #16's bodily privacy was maintained and personal space respected. Findings include: I. Facility policy The Dignity policy, revised February 2021, was provided by the director of nursing (DON) on 10/3/22 at 4:23 p.m. via email. The policy read in part: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Residents' private space and property are respected at all times. Staff speak respectively to residents at all times, including them and dressing them by name. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and didn't during treatment procedures. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example, helping the resident to keep urinary catheter bags covered. II. Resident status A. Resident #16 Resident #16, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses included personal history of transient ischemic attack (TIA) and cerebral infarction (stroke), chronic pain, urinary incontinence, difficulty walking, unsteadiness of feet, cognitive communication deficit, overactive bladder and need for assistance with personal care. According to the 7/28/22 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. The MDS assessment indicated the resident was independent in activities of daily living (ADLs). The MDS assessment identified the resident had a catheter. B. Resident interview and observation Resident #16 was interviewed on 9/27/22 at 9:04 a.m. She said sometimes she did not feel staff treated her with respect and dignity. Resident #16 said certified nurse aide (CNA) #3 had spoken to her in a very mean manner. Resident #16 said recently CNA #3 told if she wanted a shower, she needed to get her (expletive) down there right now. The resident said she personally would never use that language and felt belittled when it was used toward her. Resident #16 said she had asked CNA #3 You don't like me do you? She said the CNA said Not when you are late. She said she told CNA #3 she did not appreciate that way she talked to her but CNA #3 just Blew it off. She said when someone talks to her like that she would not forget it. She said she told other staff but was not sure who. She said she did not feel it was abusive but was not treating her with dignity. Resident #16 said CNA #3 just had a more of a gruff personality. Resident #16 said she was admitted to the facility because she needed assistance and no longer could care for herself, but felt she should not be treated that way. The resident said she knew had been a CNA for years but she did not like how she spoke to her or the tone in her voice during other interactions. Resident #16 said she had felt ignored and disrespected by CNA #9. She said she had felt ignored at times by CNA #9. She said the CNA also had passed gas in her room two or three times and did not excuse herself and giggled about it. Resident #16 said she would never not excuse herself in a similar situation and felt the giggling and repetition was disrespectful to her personal space. Resident #16 said staff did not have assistance with routine catheter care (cross-reference F690 catheter care). Resident #16 said staff were often busy taking care of other residents. (Refer observation below.) C. Observation Resident #16 was observed on 9/27/22 at 9:04 a.m. The catheter bag was observed laying on the floor uncovered, exposing the fluid in her catheter bag. Resident #16 was observed on 9/29/22 at 9:26 a.m. Her catheter bag was attached to her walker. There was not a cover over her bag for privacy. D. Record review The choices care plan, initiated on 3/11/19, read staff would ensure the resident's privacy and dignity. The depression care plan, initiated on 3/11/19 directed staff to provide support and reassurance. E. Staff interview CNA #3 was interviewed on 9/28/22 at 9:50 a.m.The CNA said staff had monthly in-services and have had annual online training on a computer based system. The staff had gone over tips on how to interact with dementia residents, right rights, dignity and abuse. She said it would never be appropriate to use swear words or be demanding of a resident. She said she asked the residents to tell her when she rushed or if she did something they did not like. She said they would usually tell her if there was a concern. CNA #9 was interviewed on 10/3/22 at 10:11 a.m. She said she has had dignity training through the facility's online program. She said the training taught her to interact and provide activity of daily living care (ADLs) with kindness. She said staff needed to make sure residents always felt comfortable. The social service director (SSD) was interviewed on 10/5/22 at 9:31 a.m. The SSD said the facility has had training on resident rights. She said the facility was the residents' home and they had the right to voice their concerns. The SSD said everyone should be treated with dignity and feel they are treated with respect. She said the perception of a resident mattered. She said staff needed to get to know the residents and how to interact with them so the residents did not have their feelings and pride hurt. The SSD said Resident #16 had not express concerns to her specific about CNA #3. The SSD said CNA #3 could exhibit tough love meaning a little rough around the edges in manner when interacting with residents. The SSD said this mannerism could potentially offend or hurt the feelings of a resident and possibly make the resident feel like they have done something wrong. The CNA comment was shared with the SSD. The SSD said if the same comment was said to her she would also feel belittled. The SSD said there was no excuse for a CNA to speak to a resident in that manner. She said she would follow up with Resident #16 to check on how she was feeling, validating her feelings of concern. The SSD said Resident #16 had not express concerns to her specific about CNA #9. She said CNA #9 sometimes could become easily side tracked which residents could take personally because they could feel ignored. The SSD said a resident's room was a resident's personal space and all they have for themselves. She said the resident's room and personal space should be treated with respect. The SSD said if a CNA had to pass gas in a resident's room, the CNA should excuse themselves and apologize. She said CNA #9 did not always handle herself professionally. The SSD said on 10/3/22 Resident #16 told her she would like to talk about a CNA. The SSD said she had not been able to follow up with the resident or know which CNA the Resident #16 or what it was regarding. The SSD said normally she would meet the resident right away or at least within the same day of the request however, she said she had not been available to meet with Resident #16 yet but would as soon as possible. The SSD said the facility had training on resident rights. She said she did not recall if it was part of their new hire orientation but it was included in an online training and review. She said the facility used to have in person training which was more helpful in understanding the perspective of a resident. She said all staff were involved in the in-person training and it encouraged staff participation and teamwork.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to fully ensure residents had the right to formulate advance directives by not keeping advance directives updated and current for two (#12 and #27) out of 16 residents reviewed for advance directives out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #12 had the proper legal representation in the record and the medical orders for scope of treatment (MOST) form, the facility utilized for advance directives, was signed appropriately; and -Ensure Resident #27's physician order matched her wishes as signed on the MOST. Findings include: I. Professional reference The Colorado Advance Directives Consortium, Guidance for Health Care Professionals website, dated [DATE], retrieved on [DATE] from http://www.coloradoadvancedirectives.com/wp-content/uploads/[DATE]-MOST-Booklet-REV-2015.pdf read in pertinent part, If the individual resides in a nursing facility, the facility staff are responsible for keeping the MOST form updated. Staff should complete MOST forms for all current residents before the next scheduled quarterly care plan meeting and review the form automatically before each resident's quarterly assessment. For current residents, complete or review at quarterly conference(s). For section A of the form, cardiopulmonary resuscitation (CPR), selecting ' Yes CPR ' requires choosing Full Treatment in section B. The form must be dated. A revised MOST form automatically supersedes all previously completed MOST forms. The MOST form must be completed by a healthcare professional with sufficient expertise to discuss medical conditions, treatments, risks and benefits with the individual. This professional should be competent and comfortable with conducting this kind of conversation. The form must be signed by a physician (MD or DO), advanced practice nurse, or physician's assistant and the individual, assuming the individual has decisional capacity. II. Resident #12 A. Resident status Resident #12 , age [AGE], was admitted to the facility on [DATE]. According to the [DATE] computerized physician orders (CPO), the diagnoses included type II diabetes mellitus with diabetic nephropathy, essential primary hypertension, acute and chronic respiratory failure with hypoxia (low blood oxygen), diabetic chronic kidney disease, dementia, and unspecified visual disturbances. The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for a mental status score (BIMS) of two out of 15. She required extensive assistance of one person with bed mobility, dressing, eating, and personal hygiene. B. Record review The care plan, initiated [DATE], identified that the resident had impaired cognitive function/dementia or impaired thought processes related to age and dementia. An intervention was put into place to ask the resident yes/no questions to determine the resident's needs. The [DATE] CPO included the following, both starting on [DATE]: Advance Directive: do not resuscitate (DNR) The resident is not capable of understanding her rights, reason: Dementia. The MOST form was signed by Resident #12 on [DATE], followed by the physician signature on [DATE]. -The medical record did not have any legal authority for medical decisions. However, in the computerized medical record a letter of conservatorship-adult dated [DATE], appointed an attorney as a conservator for the resident on [DATE]. The conservatorship had no authority on medical decisions. -No documentation noted for Resident #12 having a medical durable power of attorney. C. Interviews The social service director (SSD) was interviewed on [DATE] at 9:22 a.m. The SSD said the resident was severely impaired cognitively since admission. She said she scored a two on the BIMS assessment. She said an attorney acts on her behalf. The SSD was not aware the attorney did not have medical decision authority. She reviewed the conservatorship letter and confirmed it did not include medical decisions. She said due to the residents severe cognitive impairments, she should have not signed her MOST form. Certified nurse aide (CNA) #3 was interviewed on [DATE] at 12:21 p.m. CNA #3 said the resident's cognitive status was impaired. She said that she was not able to make daily decisions. She said there had been no change in her cognitive status since admission. III. Resident #27 A. Resident status Resident #27, age less than 60, was admitted on [DATE]. According to the [DATE] CPO diagnoses included, osteoporosis and depression. The [DATE] MDS assessment showed the resident did not have any cognitive impairments with a score of 15 out of 15 on the brief interview for mental status. The resident was independent in activities of daily living. B. Record review The [DATE] plan of care note showed the MOST form was changed to a do not resuscitate. The MOST form was signed on [DATE] by the resident for a do not resuscitate. The physician signed the form on [DATE]. The physician order in the computerized record on [DATE] showed the physician order was for CPR full code status. C. Interview The director of nurses (DON) was interviewed on [DATE] at 8:57 a m. The DON said that the physician's order was updated to match the MOST form. She said she did not know how the change in the MOST form was missed. She said the physician order should always match the resident's wishes with the MOST form. She said that the physician was contacted and the order was changed to a do not resuscitate.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure two (#17 and #31) of three residents reviewed for abuse out of 26 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #17 and #31 were kept free from abuse by Resident #4. Cross-reference F744, dementia care. Findings include: I. Facility policy The Abuse and Neglect policy, revised September 2018, was provided by the director of nursing (DON) on 9/29/22 at 4:05 p.m. It documented the following, in pertinent part, Every resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; neglect; explotation; involuntary seclusion; and any physical or chemical restraint not required to treat the resident's medical symptoms or conditions. The administrator was responsible for the oversight and implementation of the Abuse, Neglect, and Exploitation Prohibition and Prevention Program. If the allegation involved another resident, the residents were separated, and other reasonable measures, as appropriate (such as a psychiatric evaluation), were put into place, pending the outcome of the investigation. II. Resident-to-resident altercation involving Resident #4 and Resident #31 on 6/27/22 The facility documentation from 6/28/22 revealed Resident #4 was in another resident's room. Residents #31 heard a resident scream and went to her room. He saw Resident #4 standing in the room so he took Resident #4 by hand to escort him out of the resident's room and into the hallway like the staff had done. Resident #4 said something that Resident#31 did not understand and he responded, We are going down here. Resident #4 swung his arm and Resident #31 blocked it with his left arm. Resident #4 ended up on the floor. Resident #31 had a bruise to his posterior forearm. -The facility unsubstantiated that abuse occurred. III. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the September computerized physicians orders (CPO), the diagnoses included unspecified dementia, psychotic disturbance, mood disturbance, depression, and generalized anxiety disorder. The 6/20/22 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. He had inattention and disorganized thinking. He required supervision with dressing and was independent with all other activities of daily living (ADL). He had no behaviors and did not reject care. He wandered daily which placed him at risk of getting into a potentially dangerous place. He received anti anxiety medication daily. B. Record review The mood care plan, revised 7/7/22, documented the resident had alterations in mood and behaviors as evidence by outburst. The goal was to have fewer episodes of outburst of anger. Pertinent interventions listed were to administer medications as ordered and monitor/document side effects and effectiveness, anticipate and meet the residents needs, minimize potential for the resident's disruptive behaviors by offering tasks which divert attention, provide a program of activities that is of interest and accommodates resident status, and provide positive reinforcement/praise of the resident's progress/improvements/control in behavior. The dementia care plan, revised 7/7/22, documented the resident may have days where he became physically and/or verbally towards staff and others due to poor impulse control. Pertinent interventions listed were to speak to him in a calm, quiet voice and activities. The September 2022 behavior monitoring documented five episodes of grabbing, hitting or pushing others, expressing anger or agitation and three episodes of wandering. There were no progress notes nor interdisciplinary team (IDT) notes in the resident's medical record. IV. Resident #31 A. Resident status Resident #31, age [AGE], was admitted on [DATE]. According to the September CPO, the diagnoses included chronic obstructive pulmonary disease with acute exacerbation, acute and chronic respiratory failure with hypoxia, dyspnea (difficulty breathing), anxiety disorder, and depressive disorder. The 8/30/22 MDS assessment revealed, the resident was cognitively intact with a BIMS score of 15 out of 15. He had no behaviors and did not reject care. He was independent with all his ADLs. B. Record review The elopement care plan, revised 5/5/22, documented the resident was an elopement risk and wandered. Pertinent interventions listed were to personalize his room with familiar objects, make staff aware of elopement risk, and utilize check in/out log. -There were no progress notes nor IDT notes in the resident's medical record. V. Resident-to-resident altercation involving Resident #4 and Resident #17 on 6/30/22. The facility documentation from 6/30/22 revealed Resident #4 was standing in front of Resident #17's room entrance where he was sitting in his wheelchair. A nurse heard Resident #17 yelling and when she exited the nurses station she saw Resident #4 swing his arm to hit Resident #17. The nurse yelled to Resident #4 to stop. Resident #4 walked away, entered and exited an empty room, and exited down the hallway. The nurse went to escort Resident #4 from the area. Resident #4 shoved the nurse in her left shoulder with his right shoulder as she approached. Another staff member intervened and escorted Resident #4 off the east wing and back to the west wing where his room was located. Resident #17 stated Resident #4 had hit him. A red mark was noted to Resident #17's neck, which faded in a short time. Resident #4 was placed on one-on-one monitoring (during the investigation) and then every 15 minute checks thereafter. -The facility unsubstantiated that abuse occurred. VI. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, the diagnoses included major depressive disorder, cognitive communication deficit, conductive hearing loss, spinal stenosis, chronic respiratory failure, weakness, and dementia. The 7/28/22 MDS assessment revealed, the resident was unable to complete the BIMS. He had short and long term memory problems. His cognitive skills for daily decision making were severely impaired. He had inattention and disorganized thinking. He required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. He had no behaviors and did not reject care. He wandered one to three days out of the seven day look back period. B. Record review The dementia care plan, revised 12/2/21, documented the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. Pertinent interventions listed were to administer medications as ordered and monitor/document for side effects and effectiveness. Ask yes/no questions in order to determine the resident's needs. The 6/30/22 nurse progress note documented Resident #17 was sitting in his wheelchair in the doorway to his room, when Resident #4 walked up to him and hit him on the left cheek and neck area. It documented there were three red marks on the left side of his neck. There were no other injuries noted. VII. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 9/29/22 at 3:52 p.m. He said Resident #4 wandered and tried to hug and kiss other residents and staff. He said Resident #4 had altercations in the past and wandered into other resident's rooms. He said the staff tried their best to keep him out of other resident rooms. CNA #5 said on one occasion Resident #4 swung at him as he attempted to escort him out of a resident's room. He said on one occasion Resident #4 walked into a female resident's room and she started screaming because she was fearful of him. So, he escorted Resident #4 out of her room. He said they were doing every 15 minute checks and some of the residents have a stop sign across their door. Licensed practical nurse (LPN) #1 was interviewed on 9/29/22 at 4:07 p.m. She said Resident #4 had dementia and if you argued with him he would get aggressive. She said the staff tried to redirect him by giving him something to read or write. She said she had only been working at the facility for a month and had not seen him in any altercations. She said sometimes Resident #4 would wander into other resident rooms and the other residents would get angry and ask the staff to remove him from their room. She said Resident #4 was on every 15 minute monitoring. The executive director (ED) was interviewed on 10/4/22 at 2:50 p.m. She said the 6/27/22 resident to resident altercation was not substantiated because where the bruise was located on Resident #31's arm was not consistent with where he would have been injured from blocking the swing. She said Resident #4 acted that way when he felt threatened or when yelled at. She said he was at risk for becoming a victim and would defend himself. -However, the abuse should have been substatied because Resident #31 had a bruise on his forearm after the altercation. She said the 6/30/22 resident to resident altercation was not substantiated because during the investigation, the nurse said she was not sure if contact was made or not. The ED said the residents involved did not remember the incident and the nurse stated Resident #4 did not shove her but had bumped into her. She said Resident #4 was placed on one-to-one supervision until the initial investigation was completed and then placed on every 15 minute monitoring. She said the staff had educated the other residents about his wandering. She said residents were offered stop signs to place in their doorways if they did not want Resident #4 to wander in. She said they increased staff awareness of his wandering to the east wing. -However, the abuse should have been substatied due to the resident's report that he was hit and had marks on his neck.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #34 A . Resident status Resident #34, age [AGE], was admitted on [DATE]. According to the September 2022 CPO diagnosis included, Alzheimer's disease, anxiety and depression. The 6/5/22 MDS assessment revealed the resident had severe cognitive impairment with a score of two out of 15 on the brief interview for mental status. The resident was independent in walking and required limited assistance with all activities of daily living. The MDS assessment did not determine if the resident experienced falls prior to admission, therefore, no evidence the resident fell at home or in the community of prior to admission. The 9/5/22 MDS coded the resident has had two falls since last quarter. B. Record review Review of the resident's September 2022 medication administration record (MAR) and treatment administration record (TAR) revealed the resident had orders to receive the following medication: -Fluoxetine 20 mg by mouth one time a day with the associated diagnosis of depression. Start date of 6/23/22. Failure to act upon pharmacist recommendations The 8/6/22 pharmacist's consultation report requested for the resident's recent falls, showed the combination of a Benzodiazepine, Alprazolam and the Fluoxetine (antidepressant). The recommendation was to gradually reduce Fluoxetine HCL and then discontinue. The pharmacist suggested, 10 mg every day for 14 days, then 10 mg every other day for 14 days then discontinue. The recommendation for the Fluoxetine had not been followed by the facility as staff continued to administer the Fluoxetine daily after 8/6/22. Nor was there any effort by the facility to outreach the primary care provider to sign off on the pharmacist's recommendations to start the weaning process as advised. C. Staff interview The pharmacist was interviewed on 10/4/22 at 5:45 p.m. The pharmacist reviewed the record and confirmed the recommendation of completing a gradual dose reduction on the Fluoxetine and then to discontinue. She said the resident continued to receive the 20 mg of Fluoxetine and the recommendation had not been resolved. Based on record review and staff interviews, the facility failed to act upon recommendations by the pharmacist in a timely manner, based on medication regimen review (MRR) for two (#28 and #34) of six reviewed for unnecessary medications out of 26 sample residents. Specifically, the facility failed to ensure response to pharmacist recommendations for: -Resident #28, a discontinue order for diazepam (anti anxiety medication) and an order for serum creatinine laboratory (lab) level was not drawn as requested; and, -Resident #34, failed to ensure the drug regimen review was acted upon in a timely manner. Findings include: I. Facility policy and procedure The Unnecessary Medications policy and procedure, last revised 4/9/07, was provided by the director of nursing (DON) on 9/29/22 at 4:05 p.m. It read in pertinent part: The facility must evaluate the resident, the resident's medication regimen and if necessary consult with the resident's physician: when an irregularity is identified in the pharmacist's monthly medication regimen review. II. Resident #28 A. Resident status Resident #28, age [AGE], was admitted to the facility on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included unspecified dementia, altered mental status, depression, repeated falls, and muscle weakness. The 5/22/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15. She was rated as being independent to supervision only with her activities of daily living (ADLs). B. Record review Review of the resident's medication administration record (MAR) and treatment administration record (TAR) revealed the resident had orders to receive the following medication: -Diazepam, 5mg tablet, one tablet every eight hours as needed for anxiety. Failure to act upon pharmacist recommendations The 8/7/22 pharmacist's consultation report requested for a serum creatinine lab to be performed to check the resident's renal function, as she had not had one within the past six months. This was a second request, the first request occurred on 5/10/22. The consultation report also requested the diazepam medication be discontinued. This was the second request, as the first time occurred on 5/10/22. C. Staff interview The pharmacist was interviewed on 10/4/22 at 5:45 p.m. The pharmacist said she reviewed the resident's record once a month. She said once she makes a recommendation, the physician has 30 days to respond to the recommendation. The pharmacist reviewed Resident #28's consultation report and confirmed she had provided the recommendations. She said that she had not received an answer as to whether the recommendations were accepted. She said when she completed the drug review of the resident's medications, she emailed the recommendations to the nursing home administrator (NHA) or DON, and that it was left up to the facility to contact the physician. She said when she reviewed the resident's record again the following month, she looked for the follow up to the previous month's recommendations.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for one (#9) of five residents reviewed for immunizations out of 26 sample residents. Specifically, the facility failed to provide the pneumococcal 23-valent polysaccharide vaccine (PPSV23) to Resident #9. Findings include: I. Professional standard According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2020, retrieved from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf (10/6/2022), the routine pneumococcal vaccination for adults aged 65 years or older and were immunocompetent, one dose of PPSV23 should be administered. II. Record review A. Resident #9 Resident #9, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included chronic respiratory failure with hypoxia (lack of blood oxygen). The 7/6/22 minimum data set (MDS) assessment revealed the resident was unable to complete the brief interview for mental status (BIMS). He had no behaviors and did not reject care. The resident's pneumococcal vaccination was not up to date and it was offered but declined. Resident #9's immunization record revealed the consent for the pneumococcal vaccination was signed by the resident on 6/29/22 giving permission to receive the vaccination. Review of the medication administration record (MAR) revealed the resident never received the vaccination. III. Staff interviews The admission nurse (AN) was interviewed on 10/3/22 at 10:27 a.m. She said when a resident was admitted they were offered the COVID 19 vaccination, the influenza vaccination and the pneumococcal vaccination. She said the resident signed a consent form for the vaccination and it was given to the assistant director of nursing (ADON) who was the infection preventionist (IP). She said the facility did not have an ADON for the past few months and she was not sure who the IP was at the facility (cross-reference F882). The director of nursing (DON) and acting IP was interviewed on 10/4/22 at 2:01 p.m. After reviewing the residents immunization record, she said she was not sure why Resident #9 was not given the pneumococcal vaccination. She said she would immediately get a physician's order and order the vaccination from the pharmacy.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0574 (Tag F0574)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to post a list of names, addresses and telephone numbers of all pertinent State Agencies in the facility. Findings include: I. Group interview The group interview was conducted on 9/28/22 at 1:35 p.m. The group consisted of six alert and oriented residents selected by the facility. All six residents (#3, #16, #20, #22, #31 and #33) said they did not know where the facility posted information in regard to pertinent State Agencies' contact information. II. Observations Observations throughout the building revealed there was a posting which was located to the right of the front door. The posting was approximately five feet and five inches inside a glass case. The print was between a 12 and 14 font. The phone number to the State Survey Agency was incorrect and no email address was provided. Although there were mailing addresses and telephone numbers of pertinent State Agencies there were no email addresses. In addition, there was a posting of the ombudsman information on D hallway, which was in Spanish. An English version was not found hanging in the facility. II. Interviews The social service director (SSD) was interviewed on 9/5/22 at 9:49 a.m. The SSD confirmed, the posting of the pertinent agency information was not in a location which could be easily seen reasonably because of the height and the font of the posting. She was not aware the residents were not aware of where to find the information. The SSD said she was not aware the email address needed to be included and that that the phone number was incorrect.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observations, record review, and interviews, the facility failed to make information on how to file a grievance or complaint available, maintain records of grievances and complaints, or to make prompt efforts to resolve grievances the resident(s) may have had. Specifically the facility failed to ensure: -Resident group grievances were resolved; and, -Individual resident grievances were resolved; Findings include: I. Facility policy and procedure The Grievance and Complaints policy and procedure, revised in April 2017, was received from the director of nursing (DON) on 10/4/22 at 10:30 am, read in pertinent part, All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. The investigation and report will include, as applicable, date & time of the incident, circumstances and location of the incident, the witnesses, the residents and the employees account of the incident, and corrective actions. The Grievance Officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log with the same information. The Resident Grievance/Complaint Investigation Report Form will be filed with the administrator within 5 working days of the incident. Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions within ___ (no time frame filled in) working days of the filing of the grievance or complaint. The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. A copy of the :Resident Grievance/Complaint Investigation Report Form must be attached to the Resident Grievance/Complaint Form and filed with the business office. Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. II. Resident group interview The resident group interview was conducted on 9/28/22 at 1:35 p.m. The group consisted of six alerts and oriented residents (Resident #3, #16, #20, #22, #31 and #33) selected by the facility. The residents stated the following: Certified nurse aide (CNA) #9 had long fingernails which jabbed the residents during care. The residents were told to fill out a grievance form prior to the resident council meeting, so that the issue was not brought up in the council meeting. No staff gets back to counsel with resolutions from complaints. No staff told the council why the grievance was not addressed. The staff came to the answer call light but turned it off and did not return for 10-15 minutes. III. Record review The Resident Council minutes from June 2022 to August 2022 were reviewed and revealed: Call lights were being shut off and no staff returning to provide the care; CNAs not providing care when they should; and, using personal cell phones during work hours. In regards to nurses and CNAs, Still need to work on past grievances IV. Resident reports regarding CNA #9 A. Facility policy and procedure The Rules of Conduct policy, undated, was provided by the nursing home administrator on 10/4/22 at 5:21 p.m. The policy read in pertinent part, fingernails must be clean, neatly trimmed and not extend beyond the end of the finger for safety and infection control. B. Observations Throughout the survey starting on 9/26/22 through 10/5/22 CNA #9 was observed to work the A hallway. She had long artificial nails which were nearly an inch over the nail bed. C. Resident interview Resident #36 was interviewed on 9/26/22 at 4:41 p.m. He said CNA #9 long nails sometimes pinched him if she was providing occasional care assistance. D. Interview The SSD was interviewed on 10/5/22 at 10:46 a.m. She said residents have submitted a formal complaint about CNA #9's nails. She said the residents wanted her to cut her nails, they were too long. The residents said her nails would jab/poke them during cares. The SSD said the grievance form, submitted by residents about a month ago, was somewhere in her paper piles. She said the form was only partially completed because she was told by management that the nails were an appropriate length. She said there was no attempted resolution to the concern that she was aware of. V. Call lights A. Record review The facility was unable to provide any grievance form or audit which was completed to show the grievance was followed up on. B. DON interview The DON was interviewed on 10/4/22 at 11:00 a.m. The DON said the call lights should be answered by any staff member, but if care was needed the call light needed to remain on. VI. Additional interviews The SSD was interviewed on 10/5/22 at 9:00 a.m. She explained the activity director (AD) was responsible for the resident council and grievances/complaints. She said there should be a response within 72 hours. She has created a form for residents to use to file a complaint or grievance. She said she was not familiar with how the grievance process worked in the entirety. She said she had not heard the call light issue. The SSD said residents should always be informed of any follow up on their grievance. The AD was interviewed on 10/5/22 at 2:00 p.m. The AD confirmed residents were asked to file a grievance prior to the resident council, as that way the complaint could be handled at an earlier date. She said she had not filled out any grievance forms from the resident council. She said she was not familiar with the policy.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** V. Resident #34 A. Resident status Resident #34, age [AGE], was admitted on [DATE]. According to the September 2022 CPO diagnosis included Alzheimer's disease. The 6/5/22 MDS showed the resident had severe cognitive impairments with a score of two out of 15 for the brief interview for mental status. The resident required limited assistance with activities of daily living. B. Observations On 9/27/22 at approximately 12:00 p.m., the resident had both upper and lower natural teeth, although some were missing and some were fragments. C. Record review The MDS inaccurately coded the dental for Resident #34.The MDS indicated she had no natural teeth, whereas, she did have natural upper teeth with missing incisors bilaterally, and a lower partial. II. Resident #26 A. Resident status Resident #26, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, other fracture of first lumbar vertebra, and repeated falls. The MDS assessment on 8/17/22, revealed that the resident was cognitively intact on the brief interview for mental status (BIMS) with a score of 15 out of 15. The MDS revealed the resident needed limited assistance to extensive assistance with activities of daily living (ADLs). B. Observations and interview Resident #26 was interviewed in her room on 9/27/22 at 10:08 a.m. She said she was not using her upper denture because it needed to be realigned. She said it slipped so she did not use it. C. Record review The 8/10/22 MDS assessment for dental was not completed. The 8/17/22 MDS assessment for dental did not identify any dental problems with Resident #26. -However, the loose fitting denture should have been coded. III. Resident #33 A. Resident status Resident #33, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, diagnoses included age-related osteoporosis, osteoarthritis, essential (primary) hypertension and type 2 diabetes mellitus with diabetic polyneuropathy. The MDS assessment on 3/3/22, revealed that the resident was cognitively intact with the BIMS score of 15 out of 15. The MDS revealed the resident was independent with ADLs. B. Observations and interviews On 9/30/22 at 9:46 a.m., the resident ' s mouth exhibited missing and broken natural teeth. The resident reported that she only has four of her bottom teeth, and no teeth on the top. C. Record review The care plan, initiated on 5/24/21, identified the resident as having missing teeth on both the upper and lower portion of mouth. The 3/3/22 MDS assessment was assessed as the resident having no dental problems. -However, the MDS should have been coded as having some natural teeth and tooth fragments. IV. Staff interviews The nursing home administrator (NHA), who is a registered nurse, was interviewed on 10/5/22 at 2:30 p.m. The NHA said the MDS coordinator was not available. She reviewed the MDS for Resident ' s #26 and #33. The NHA confirmed the dental portion of the assessments were not completed accurately. Based on record review and interviews, the facility failed to ensure the minimum data assessment (MDS) accurately reflected the residents' status for four (#5, #26, #33 and #34) of 12 out of 26 sample residents. Specifically, the facility failed to ensure the MDS for Resident #5, #26, #33 and #34 were completed accurately to include their dental status. Findings include: I. Resident #5 A. Resident status Resident #5, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the September 2022 computerized physicians orders (CPO), the diagnoses included paraplegia (paralysis lower body), cognitive communication deficit, age related physical debility, repeated falls, and unsteadiness on feet. The 9/21/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. She had no behaviors and did not reject care. Section L (Dental) documented Resident #5 did not have mouth or facial pain, discomfort or difficulty with chewing. B. Family interview Resident #5's power of attorney (POA) was interviewed on 9/28/22 at 6:07 p.m. She said Resident #5 had been having mouth pain and was losing weight. She said Resident #5 had seen the dentist who suggested a mechanical soft diet due to her age and the pain of pulling all of her lower teeth and giving her dentures. She said once the diet was changed to mechanical soft, she started gaining weight. C. Record review The care plan, initiated 6/30/18 and revised on 7/10/18, identified the resident had upper dentures and her own lower teeth. D, Staff interviews Certified nursing aide (CNA) #5 was interviewed on 10/1/22 at 4:32 p.m. He said Resident #5 had upper dentures and her own lower teeth. He said he had never heard her complain of mouth pain, and she received a mechanical soft diet for chewing difficulties. The executive director (ED) was interviewed on 10/5/22 at 2:30 p.m. She reviewed Resident #5's medical record and acknowledged section L of the MDS was not recorded accurately. She said when the MDS was completed, they were to visibly assess the resident and review the documents to make sure the medical record was accurate.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the September 2022 CPO diagnoses include, adult failure to thrive, unsteadiness to feet and hypertension. The MDS assessment on 6/29/22 revealed he refused to complete the BIMS score. The resident required limited assistance with activities of daily living. He had no behaviors and did not reject care. B. Resident interview Resident #9 was interviewed on 9/26/22 at 9:45 a.m. The resident said it was his choice to not wear a mask and he did not feel that the facility liked him because he refused to wear a mask or to get vaccinated. He said they made him stay in his room because he did not want to wear the mask. He said when he had attended a music event he was asked to leave as he did not have a mask on. The resident said he did get lonely because he was alone in his room the majority of the time. The resident stated he enjoys watching western movies and reading western books as it reminds him of growing up on a farm. The activity director (AD) was notified of the resident's interests after the interview. The resident was interviewed a second time on 9/27/22 at 9:00 a.m. The resident said he did not get any individualized activities offered to him. In the resident's room, were a few books provided by the AD. C. Record review The care plan dated 6/30/22 identified the resident has little or no programming involvement related to disinterest, physical limitations, and poor adjustment to the facility/unit/community, The resident wishes not to participate and can participate in activities of his choice. Goals: 1) participate in programs of interest when I choose, 2) establish and record the residents prior level of programming involvement and interests by talking with the resident, caregivers, and family on admission and as necessary, 3) the resident has a TV in his room if he cares to watch it, 4) the resident likes to watch wild life out his window, 5) the resident prefers to visit with others in small groups, 6) the resident socializes with friends and family D. Staff interview The activity director (AD) was interviewed on 10/4/22 at 9:01 a.m. The AD said she was not all that familiar with the resident. She said that when she had attempted to visit with him, he had asked her to leave his room. She said she had not been able to get a good activity assessment due to his refusal to answer questions. The AD stated the resident had calmed down a little but he's not happy with his situation and cannot participate in activities without a mask. She said the resident was lonely, needed a friend and stimulation but did not currently have a one-on-one program. IV. Resident group interview regarding activities A. Resident group interview The resident group interview was conducted on 9/28/22 at 1:35 p.m. The group consisted of six alert and oriented residents (#3, #20, #22, #31, and #33) selected by the facility. The residents stated the following: -They would like to have more evening activities; and -They would like to have more outings. The residents said the van had two spots for wheelchairs, but in reality it was only one, as it was too small for two residents. They said that not much was happening in the evening. B. Record review The activity calendar for August, September and October 2022 showed the following: July 2022 -An outing was scheduled for Wednesdays. The outing for 7/13/22 was canceled. -Bingo at 6:30 p.m. three times in the month. -Yard games at 6:30 p.m., one time for the month. August 2022 -An outing was scheduled for two Wednesdays and 8/9/22. The 8/9/22 outing was canceled. -Yard games at 6:30 one time a week for three weeks. -Bingo at 6:30 p.m. once a month. September 2022 -An outing was scheduled for 9/7 and 9/14/22. The 9/14/22 outing was canceled. -Yard games at 6:00 p.m. one time a week for two weeks. -Bingo at 6:30 p.m. twice a month. C. Staff interview The AD said that she wrote the activity calendar and she made sure she had an evening activity once a week. She said outings were also scheduled once a week and on Wednesdays, however, the van was having issues and it has been broken. She said it had been broken for a couple of weeks. She said as the van only held one resident then the residents in wheelchairs who can not transfer into a van seat needed to take turns. She said she would talk with the residents to ask what type of evening activities they would like. Based on interviews, observations, and record reviews, the facility failed to provide an ongoing program to support residents in their chosen activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#9 and #12) of five out of 26 sample residents. Specifically, the facility failed to: -Offer and provide personalized activity programs for Resident #12 and Resident #9; and, -Offer evening and activity outings. Findings include: I. Facility policy and procedure The Activities Program policy, effective 9/1/14, was received from the director of nurses on 10/3/22 at 4:23 p.m. It was documented in the pertinent part, The community will encourage participation in independent or self-driven activities, as well as offer activities at least three times per week. II. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia (low blood oxygen), dementia, and essential primary hypertension. The 7/8/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a score of two out of 15 on the brief interview for mental status (BIMS). The MDS assessment coded that the resident required extensive assistance with activities of daily living, and that she did not have an altered level of consciousness. The preference for activities documented, the resident reported that being around animals and performing her favorite activities were somewhat important to her. B. Resident observations On 9/26/22 at 2:05 p.m. the resident was lying in bed awake, the television was on, but on a static channel (just showing snow). No other meaningful activities taking place. On 9/29/22 at 8:50 a.m. the resident was lying in bed with the television turned off. C. Record review The comprehensive care plan, dated 5/5/22, documented as a goal is that the resident would participate in a one-to-one program, three times a week, noting the resident enjoyed watching television. It was identified that on 8/3/22 the resident was dependent on staff for her emotional, intellectual, physical, spiritual and social needs. With a goal that she will maintain involvement in cognitive stimulation and social programs. The resident's activity log, received from the activities director (AD) on 9/30/22 at 4:19 p.m., revealed that for the week of 8/28/22 to 9/3/22, the resident was only offered an activity on one day, 9/1/22. The medical record failed to show the resident was on a one-to-one program. D. Staff interviews The AD was interviewed on 10/4/22 at 9:01 a.m. She said that when she went into the resident's room, she ensured the television was on. She said the resident had declined music in the past. The AD reported that she could probably do better with activity visits. She said she was training staff on documentation.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the September 2022 CPO diagnosis included muscular sclerosis. The 6/19/22 MDS showed the resident had severe physical limitations in ability to transfer and ambulate. He was unable to stand or walk and is wheelchair bound. B. Resident interview Resident #3 was interviewed on 9/27/22 at 9:20 a.m. The resident said he had severe limitations in his ability to transfer and ambulate due to muscular sclerosis. He did not receive any restorative services, and no range of motion. He said he thought it was due to staffing shortages. He said his physical and occupational therapy was discontinued earlier in the year. C. Record review The care plan dated 2/3/22 per rehabilitative services, identified the resident had limited range of motion and recommended a restorative program for 1) at least 15 minute assist to setup with ADLs and allow the resident to complete as much as he can.2) Restorative strengthening program: for lifting his water cup up/down 5 times and repeating 3 more times, make a fist then straighten his fingers out 5 times. The occupational therapy notes dated 8/1/22 revealed the occupational therapist discharged him to a restorative program, focusing on strengthening the right upper extremity during self feeding and activities of daily living tasks. -The medical record failed to show any evidence that the resident received any range of motion services as part of the restorative program. C. Observation On 9/27/22 at 9:20 a.m., the resident was sitting in his electric wheelchair. The resident had limited mobility on both of his upper and lower extremities. At 12:15 p.m, the resident was at the dining room table. The resident was receiving assistance from a certified nurse aide with eating due to his limited upper extremity mobility. D. Staff interview The DON was interviewed on 10/3/22 at 4:10 p.m. The DON said there was no official restorative program available at this time. She said CNA #4 was assigned to the role but works three days a week. She said CNA #4 was currently on leave. The DON said a restorative program was currently in the works. Based on observations, record review and interviews, the facility failed to ensure two (#3 and #5) of three residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion, out of 26 sample residents. Specifically, the facility failed to establish a consistent restorative nursing program within the facility to ensure Resident #5 and Resident #3 did not have a potential decline in activities of daily living (ADL). Findings include: I. Facility policy The Restorative Nursing Services policy, revised July 2017, provided by the director of nursing (DON) on 9/29/22 at 4:05 p.m., read in pertinent part: Restorative nursing care consists of nursing intervention that may or may not be accompanied by formalized rehabilitative services (physical, occupational or speech therapies). Restorative goals and objectives are individualized, resident-centered, and are outlined in the resident's plan of care. Restorative goals may include, but are not limited to supporting and assisting the resident in: -Adjusting or adapting to changing abilities; -Developing, maintaining or strengthening his/her physiological and psychological resources; -Maintaining his/her dignity, independence and self-esteem; and -Participating in the development and implementation of his/her plan of care. II. Resident #5 A. Resident status Resident #5, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the September 2022 computerized physicians orders (CPO), the diagnoses included paraplegia (paralysis of lower limbs), cognitive communication deficit, age related physical debility, repeated falls, and unsteadiness on feet. The 9/21/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. She had no behaviors and did not reject care. The resident had left and right sided impairment of both the upper (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot); did not walk; and required extensive assistance with bed mobility and dressing; and was totally dependent on staff with transfers, eating, toilet use, personal hygiene and physical help in part of bathing. According to the MDS assessment, the resident did not receive restorative nursing services. The last time the resident received physical therapy services was from 7/26/22 to 8/11/22 and occupational services from 6/27/22 to 8/3/22. B. Observations and interview Resident #5 was observed on 9/26/22 at 11:23 a.m. Resident #5 was observed sitting in her wheelchair with her right arm flaccid laying in her lap. She did not have any type of splint on her right arm/wrist to prevent contraction. The resident was able to answer a few questions with yes and no answers. Resident #5's power of attorney (POA) was interviewed on 9/27/22 at 12:42 a.m. The POA said the resident's right arm had started to get limp and the physician assessed her and determined she had a stroke. She said the physician ordered her to work with physical therapy (PT). She said the physical therapist had left a few months prior and had no therapy since then. She said the restorative certified nurse aide (RCNA) was a good CNA but did not have time for her restorative duties. C. Record review A review of the physician orders for July and August 2022 revealed the following relevant orders: -7/26/22 P.T. to evaluate and treat 20 treatments in 60 days for therapeutic activities, therapeutic exercises, neuromuscular re-education, manual techniques, and group therapy. -7/27/22 Occupational therapy order: continue occupational therapy services from 7/25/22 to 8/21/22. -8/3/22 Patient has been discharged from OT services at this time due to max progression. Patient will be set up on a restorative program to maintain progress. Occupational therapy plan of care dated 6/27/22 revealed the reason for referral was Resident #5 presented with a decline in ADL's of self care, functional mobility and transfers due to decreased ROM, strength, and coordination in right upper extremity (RUE). She required skilled therapy to improve safety, function and strength. Her discharge plan was to remain in the skilled nursing facility (SNF) with a functional maintenance program. Physical therapy Discharge summary dated [DATE] revealed Resident #5 was discharged from therapy and that the goals were partially met. Her discharge plan was to remain in the skilled nursing facility (SNF) with a functional maintenance program. D. Staff interviews The regional therapy director (RTD) was interviewed on 9/28/22 at 11:15 a.m. He said that when PT/OT discharged a resident from their program, they meet with the facility restorative nurse who contacts the physician for an order to receive restorative services. He said he did not know who the restorative nurse was at that time. He said if the resident was to remain in the facility with a functional maintenance program, the resident should be receiving restorative services from the facility. The admission nurse (AN) was interviewed on 9/29/22 at 4:14 p.m. She said the restorative nurse passed away in July 2022 so the RCNA was in charge of the restorative program. The occupational therapy assistant (OTA) was interviewed on 9/30/22 at 10:29 a.m. She said Resident #5 had been discharged from their program. She said therapy had a daily morning meeting where they discussed discharges from therapy, falls and residents they were going to pick up for therapy. She said the director of nursing (DON) communicated the discharged residents from therapy with the restorative department. She said the RCNA had been handling the restorative program. The RCNA was unavailable for interview after many attempts were made. The DON was interviewed on 10/4/22 at 2:11 p.m. She said Resident #5 did not have any restorative notes in her medical record. She said Resident #5 was discharged from OT on 8/3/22 but there was no physician order for the restorative care program. She said there was no formal restorative program at the facility.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia (low blood oxygen), dementia, and essential primary hypertension. The 7/8/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a score of two out of 15 on the brief interview for mental status (BIMS). The MDS assessment coded that the resident required extensive assistance with activities of daily living, and that she was receiving oxygen therapy. B. Record Review The care plan, initiated 5/3/22 and revised 7/8/22, identified she was at risk for an alteration in cardiovascular status with an intervention that the resident required oxygen as ordered. The care plan also identified Resident #12 as having increased risk for potential of an ineffective respiratory pattern related to the need of oxygen therapy, thus requiring continuous oxygen at a setting 2 to 3 liters per minute (LPM). The September 2022 CPO failed to show a physician order for the use of the oxygen. The CPO documented, for concentrator use (no directions specified) and portable oxygen use (no directions specified). The orders started 5/3/22. C. Observations Resident #12 was lying in bed 9/27/22 at 8:43 a.m. with a nasal cannula in place, and the oxygen concentrator was set to 8 LPM. On 9/27/22 at 2:00 p.m. the resident's nasal cannula was not in place, it was lying across her chest with the oxygen concentrator set to 8 LPM. On 9/29/22 at 8:50 a.m. the resident was lying in bed, the nasal cannula was in place with the oxygen concentrator set to 7 LPM. On 9/30/22 at 8:43 a.m. the resident was lying in bed, the nasal cannula was in place with the oxygen concentrator set to 7 LPM. D. Staff Interview Registered nurse (RN) #2 was interviewed on 9/28/22 at 1:00 p.m. She reviewed the record and was unable to locate Resident #12's oxygen orders from the physician. She said that she would ask the director of nurses (DON) about the location. E. Facility follow-up On 9/29/22 Resident #12 received a physician order which read, oxygen at 3 LPM per nasal cannula. IV. Resident #26 A. Resident status Resident #26, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, other fracture of first lumbar vertebra (backbone), and repeated falls. The MDS assessment on 8/17/22, revealed that the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident needed limited assistance to extensive assistance with activities of daily living. The resident was coded as using oxygen therapy. B. Record review The September 2022 current CPO included the following: oxygen use (canister) and portable oxygen use (both with no directions specified), started 8/10/22. The care plan, initiated 8/10/22, identified the resident was at risk for alteration in cardiovascular status and required oxygen use. Pertinent approaches were to wear the oxygen continuously via nasal cannula at 2 to 3 LPM. C. Observation On 9/26/22 at 9:23 a.m. the resident was lying in bed, with her nasal cannula in place. The oxygen concentrator was set at 4 LPM. The tubing was not labeled with the date as to when it was changed last. On 9/28/22 at 8:27 a.m., observed the resident lying in bed, with nasal cannula intact, the oxygen concentrator was set at 3 LPM. On 9/29/22 at 8:54 a.m., observed the resident lying in bed, with nasal cannula intact, the oxygen concentrator set at 3 LPM. D. Staff interview Registered nurse (RN) #2, was interviewed on 9/28/22 at 1:00 p.m. She reviewed the record and was unable to locate Resident #26's oxygen orders from the physician. She said that she would ask the director of nurses (DON) about the location. The DON was interviewed on 9/29/22 at 11:02 a.m. She said the procedure on obtaining orders for oxygen was the admission nurse ensured an order was obtained from the physician. If a resident was already part of the community, and required oxygen, then it was the responsibility of the resident's current nurse to obtain an order from the physician. She said the tubing should be changed out by the respiratory therapist, who comes to the facility every two weeks and dates when changed. E. Facility Follow up On 9/29/22 Resident #26 received a physician order which read, continuous oxygen at 3 LPM per nasal cannula. Based on observations, record review and interviews, the facility failed to provide respiratory care and services in accordance with professional standards of practice, for three residents (#7, #12 and #26) of eight residents reviewed out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #7 had oxygen in her portable tank for mobility and readily available in an event of an emergency; -Ensure Resident #7 was placed on correct order setting for oxygen via nasal cannula; -Ensure Resident #12 had a physician order for specific nasal cannula oxygen requirements and for titration of oxygen requirements; and, -Ensure Resident #26 had a physician order for oxygen. Findings include: I. Facility policy The Oxygen Concentrator policy, effective 9/1/19, was provided by the activity director (AD) on 9/28/22 at 4:00 p.m. The policy read in pertinent part: This document sets forth general information and guidelines in regards to delivering oxygen to a resident using an oxygen concentrator. Once the oxygen concentrator has been set up and positioned properly, turn to proper flow rate as ordered by the physician. According to the policy, staff were to document in the resident's medical record after the oxygen setup adjustment was performed. The documentation should include: -The date and time of the oxygen administration; -The type of delivery system; -The rate of the oxygen flow; -The oximetry results (if ordered by the physician); -The resident's vital signs, skin color, and lung sounds; -The resident's response to therapy or any respiratory distress; -The date and time of physician/family notifications; and, -The signature and credentials of the individual who performed administration of the oxygen. II. Resident #7 A. Resident status Resident #7, age [AGE], was admitted on [DATE]. According to the October 2022 computerized physician orders (CPO), the diagnoses included acute and chronic respiratory failure with hypoxia (low oxygen blood levels), chronic obstructive pulmonary disease (COPD) with acute exacerbation, dementia, anxiety, schizoaffective disorder, and bilateral macular degeneration. The 6/22/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 14 out of 15. She was independent in most of her activities of daily living (ADLs). The resident required one person physical assistance with supervision, proving oversight, encouragement or cueing. -The MDS assessment did not identify Resident #7 required oxygen therapy. B. Observations and resident interview Resident #7 was interviewed on 9/26/22 at 9:47 a.m. The resident said she needed to be on oxygen at all times because of her COPD. The resident said she should be on four liters of oxygen. Resident #7 wore nasal cannula attached to an oxygen concentrator. The concentrator was set at three liter per minute air flow. She said she could not adjust it because she could not see well so staff set her oxygen for her. She said her portable oxygen was usually empty and staff needed to fill it up for her but often did not. She said not having the portable oxygen tank filled made it difficult to use the restroom because the tubing on the concentrator would get caught on something or she would trip on it. Resident #7 said she spent a lot of time in her room but liked to walk down the halls for exercise. She said she could not leave her room when she did not have oxygen in her portable tank. The portable oxygen tank attached to her walker was observed. The tank was empty. The portable oxygen tank attached to the walker was the only portable oxygen tank in her room and within the resident's reach. The resident stated that staff often did not make sure her portable was filled at night which recently became a problem. Resident #7 said she was assisted outside during a facility evacuation on 9/23/22 after she was told by staff they smelled smoke in the facility. She had her portable oxygen tank attached to her walker but the oxygen tank was empty. She said she did not receive oxygen until the paramedics arrived and provided it to her. Cross-reference F689 accident hazards. -Resident #7 with COPD and acute and chronic respiratory failure with hypoxia was not provided oxygen continuously as prescribed in the CPO. Resident #7's oxygen concentrator and portable oxygen tank was observed on 9/27/22 at 4:15 p.m. The oxygen concentrator was set at three liters per minute and her portable oxygen tank was empty. The resident was not provided four liters of oxygen as prescribed in the CPO. Resident #7's oxygen concentrator and portable oxygen tank was observed on 9/28/22 at 12:26 p.m. The oxygen concentrator was set at three liters per minute and her portable oxygen tank was empty. At 4:20 p.m. the resident's oxygen concentrator was set at three liters per minute and her portable oxygen tank was empty. At 7:40 p.m. the resident's oxygen concentrator was set at three liters per minute and her portable oxygen tank was empty. Resident #7's oxygen concentrator and portable oxygen tank was observed on 9/29/22 at 9:01 a.m. The oxygen concentrator was set at three liters per minute and her portable oxygen tank was empty. At 10:43 the portable oxygen was full. The resident said someone (later identified as the respiratory therapist) filled her tank. Resident #7's oxygen concentrator and portable oxygen tank was observed on 9/30/22 at 9:47 a.m. The resident's portable oxygen tank was full but the oxygen concentrator was still set at three liters per minute. Licensed practical nurse (LPN) #2 reviewed the oxygen orders for Resident #7 on 9/30/22 at 9:50 a.m. LPN #2 confirmed the resident has orders for continuous oxygen at four liters per minute. She said she was not aware of any current respiratory concerns or changes for Resident #7 related to her oxygen needs. She said oxygen orders needed to be followed as directed by the physician. The LPN observed the concentrator of Resident #7 and identified the contractor oxygen level was set at three liters per minute instead of the prescribed four liters per minute. The LPN said the oxygen setting needed to be adjusted. She set the concentrator to four liters per minute. Resident #7 was interviewed again on 10/3/22 at 9:50 a.m. She said she was able to exercise down the hallways on 10/3/22 because she had air in her portable oxygen tank. Additional observations on 10/3/22 and 10/4/22 identified the resident's portable tank was half full and her oxygen tank was set at four liter per minute. C. Record review The respiratory care plan, initiated on 3/15/21, read Resident #7 had the potential and/or actual altered respiratory pattern due to inability to maintain an effective airway clearance. According to the care plan, Resident #7 should maintain a clear, open airway and have decreased risks for associated breathing symptoms/complications. The care plan identified breathing symptoms/complications could include increased respiratory rate, complaints of shortness of breath, wheezing, increased coughing or difficulty breathing. Interventions directed staff to provide the resident oxygen via nasal prongs (nasal cannula) at four liters per minute, administer medications as indicated and monitor the effectiveness of respiratory treatments. The 4/27/21 CPO for Resident #7 identified the resident had an order for continuous oxygen at four liters per minute via nasal cannula at every shift related to her acute and chronic respiratory failure with hypoxia. The oxygen saturation record between 9/17/22 and 9/29/22 for Resident #7 indicated the resident saturation levels ranged between 90% and 98% on oxygen via nasal cannula. D. Staff interview Certified nurse aide (CNA) #1 was interviewed on 9/28/22 at 8:15 p.m The CNA said the oxygen portables should have been checked once a shift. The CNA said she was one of the CNAs that worked on 9/23/22, the night of the evacuation. She said several of the residents did not have their oxygen outside with them or it was with them but the tanks were empty. The director of nursing (DON) was interviewed on 9/29/22 at 11:03 a.m. The DON said physician orders for oxygen should always be followed unless the resident was in crisis. She said the respiratory therapist checked and filled the portable oxygen tanks every one to two weeks. She said the respiratory therapist filled resident portable oxygen tanks this morning (9/29/22). The DON said the CNAs should check the resident's oxygen tanks all the time throughout the day. She said the oxygen checks were not logged. The DON was informed of the above observations. She said staff should have been ensuring the resident's orders were followed and had her tank filled routinely and as needed. The DON said residents with COPD can experience shortness of breath, difficulty breathing, and respiratory distress. She acknowledged it could be scary for a resident with COPD not to have oxygen when it was needed. A staff member who requested to remain anonymous was interviewed on 9/29/22. The staff member said Resident #7 did not tell her about the oxygen concerns she had during the 9/23/22 evacuation but had requested the portable oxygen tank to be filled every night. The staff member said the oxygen portables should always be filled during the day at night. The staff member said the facility had a new oxygen supply company. The staff member said the portables were freezing up more often and depleting faster with the new equipment, causing staff to have to fill them more often. The staff member said when the portable oxygen tanks freeze up, it prevented the oxygen air flow. The staff member said she thought management was aware of staff complaints with the tanks freezing up but they had not personally told them. The staff member said the other staff and residents often complain about the tanks freezing and not immediately ready for use. The staff member said the tanks freeze all the time so they keep one filled in the oxygen storage room at all times. They would fill a tank, set the tank on the rack in the storage room and take the tank on reserve. The staff member said if there two residents needing oxygen at the same time, one of them would have to stay on the room concentrator until a portable oxygen tank was filled, thawed, and ready for the resident. The staff member said that the portable oxygen tanks took too long to fill and when the tanks were filled the portables would freeze up. The staff member said they were just worried someone could burn up while filling the tanks, referring to 9/23/22 evacuation. The staff member entered the oxygen storage room. On a metal rack in the room were six portable oxygen tanks, five were empty and one tank was full. The staff member placed an empty portable on a large oxygen fill tank. The oxygen slowly entered the portable. After a couple of minutes, the staff member said it was taking too long to fill. The staff member switched the portable tank to a second large fill tank and attempted to fill the portable. One minute later, the oxygen was still filling. The staff member said they would feel bad if there was a resident waiting for the portable oxygen tank right now. After another minute, the staff member said the portable was starting to freeze up. The staff member said the portables usually freeze up about two out five times when trying them. The staff member said it was not good that the process for refilling tanks was so slow with new equipment and when they did fill, the portables would freeze up. RN #1 was interviewed on 9/29/22 at 5:15 p.m. The RN said she had just heard last week from a CNA that the portable oxygen tanks freeze up. She said she had not experienced that until last week. She said there were spare ones in the oxygen transfer room. RN #1 was interviewed again on 9/30/22 at 1:26 p.m. She said she would sometimes fill the oxygen tanks. She said the previous oxygen equipment was much easier to fill and use. CNA #7 was interviewed on 9/29/22 at 4:24 p.m. The CNA #7 said that the portable oxygen tanks freeze up. She said that they do not work properly. She said that the tanks can not be fully filled due to the freezing of the liquid oxygen. The nursing home administrator (NHA) and the (DON) director of nursing were interviewed on 9/30/22 at 1:40 p.m. The NHA said the facility has had the new oxygen company equipment since 7/28/22. She said the oxygen company trained some of the staff on equipment use on 7/28/22. The NHA said the staff who were trained by the oxygen company, trained the other staff. She said staff had told the NHA and the DON the portable tanks freeze up. She said they only complained of the freezing portables a couple of times when they first received the new oxygen tanks. She said the old tanks used to freeze as well. She said tanks could be more susceptible to freezing if there were changes in the air temperature or humidity. She said staff had to wait a few minutes after filling to turn the portable on so it would not freeze. The NHA said if it froze up, staff would just have to wait a few more minutes to thaw or fill another one while the resident would remain on the concentrator. The DON entered the oxygen storage room. In the storage room was a set of empty portable oxygen tanks and one partially filled tank. The DON placed an empty portable oxygen tank onto the fill tank. She said the first fill tank was not filling correctly and placed the portable tank onto a second fill tank. The fill tank slowly filled the portable oxygen tank. The DON said the tank was taking a while to fill. She said she was not aware that the tanks were taking so long to fill or it was common for them to freeze up. The DON said she would create a system to routinely fill the portable oxygen tanks, educate staff and monitor the tanks to ensure they are routinely filled. CNA #5 was interviewed on 9/30/22 at 4:30 p.m. CNA #5 said the portable tanks freeze up as they were being filled. He said, tanks and the liquid oxygen tanks do not seem to match. He said he had not received any training on the new tanks from the new company. He said all the CNAs had the same problem. CNA #9 was interviewed on 10/3/22 at 10:04 a.m. She said staff needed to make sure residents always felt comfortable. She said Resident #7 was one of the residents who needed extra attention. She said Resident #7 worried that staff do not pay enough attention to her. The CNA said she has had problems with the portable oxygen tanks freezing up sometimes if they were more than half way full or if they were overfilled. She said the tanks now take a little longer to fill either because the portable tanks were bigger than the old tanks or new oxygen equipment just filled slower. CNA #9 said she was trained how to use the oxygen equipment when the new tanks arrived. CNA #9 said she was working on 9/23/22 during the evacuation. She said she thought there was a potential fire inside the facility so she did not make the attempt to fill resident's portable oxygen tanks during the evacuation. The CNA said the portable oxygen tanks freeze up when they are filled. (Cross-reference F689 accident hazards.) E. Facility follow-up The oxygen education was provided by the facility on 10/4/22. The oxygen education was created after the facility was informed of oxygen concerns identified during the survey. The oxygen education reviewed the portable oxygen canisters (tanks.) The education reviewed when staff should fill and check the oxygen canisters; how to check portable canisters; and where to store portable canisters. According to the staff oxygen education staff should: -Fill the canisters during the night shift before resident arising in the morning; -Check the canisters before and after meals and fill if indicated; -Check the canisters before the resident goes to bed and fill if indicated; -The canisters as needed when requested by the resident; and, -Store the canisters in the residents' room.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. Cross-reference F689 accident hazards, F692 nutrition, and F744 dementia care. Findings include: I. Resident census and conditions According to the 9/26/22 Resident Census and Conditions of Residents report, the resident census was 36 and the following care needs were identified: -23 residents needed assistance of one or two staff with bathing and seven residents were dependent. Three residents were independent. -13 residents needed assistance of one or two staff members for toilet use and six residents were dependent; 15 residents were independent. -16 residents needed assistance of one or two staff members for dressing and four were dependent; 13 residents were independent. -15 residents needed assistance of one or two staff members and four were dependent for transfers; 15 residents was independent -Four residents needed assistance of one or two staff members with eating and 30 were independent. II. Staffing requirements for each station The director of nursing (DON) was interviewed on 10/4/22 at approximately 10:00 a.m. The DON provided the staffing requirements for each station. They were as follows: Hall A was to have one licensed nurse 12 hours for day shift and one certified nurse aide (CNA); Hall C and D were to have one licensed nurse 12 hour shifts from 6:00 a.m. to 6:00 p.m. and two CNAs for day shift and evening shift; and, The night shift has one licensed nurse 6:00 p.m. to 6:00 a.m. for the entire building and two CNAs for the entire building to cover all three halls. III. Observations On 9/27/22 at 5:00 p.m., the C and D hallway had only two CNAs working, however, one was clocking out at 6:00 p.m. IV. Resident council minutes The review of the Resident Council minutes from June 2022 through August 2022 revealed resident concerns -Call lights being shut off and no staff returning; -CNAs not doing care when they should; and, -Need more than one CNA at night. V. Resident interviews Resident #20 was interviewed on 9/26/22 at 9:15 a.m. She said there was not enough staff. The resident said CNAs sometimes told her they were limited on help. She said the facility was short staffed at night. She said they had to pull CNAs from other hallways to help assist residents in her hall. Resident #9 was interviewed on 9/26/22 at 9:58 a.m. The resident said his call light did not get answered timely. He said it could take an hour during the evening shift. Resident #33 was interviewed on 9/26/22 at 10:39 a.m. The resident said staffing was short, that her call light was not answered timely and that it could take up to 30 minutes. Resident #26 was interviewed on 9/27/22 at 10:01 a.m. The resident said her call light was not answered timely. She said she has had to wait for a few hours. She said often times there was only one CNA for both C and D hallway. She said it was especially difficult to have call light answered right after dinner when others have to go to the bathroom. Resident #35 was interviewed with her family member on 9/28/22 at 10:40 a.m. The family member said Resident #35 has long waits for activity of daily living (ADL) assistance because staff have to spend so much time with the wandering residents (Cross-reference F744 dementia care). VI. Resident group interview The resident group interview was conducted on 9/28/22 at 1:35 p.m. The group consisted of six alert and oriented residents (#3, #20, #22, #31, and #33) selected by the facility. The residents stated the following: -Not enough nursing staff during the evening or night; -Call lights were not answered timely, and the staff shut the call light off and do not return; -Call lights can take up to 30 plus minutes to wait for call light to be answered; and, -Administration told the residents that the facility could not afford anymore staff, and that they were staffed accordingly. VII. Family interview The family member of Resident #35 was interviewed again on 10/3/22 at 1:10 p.m. The family member said he felt frustrated. The family member said Resident #35 had to wait over 45 minutes to have her brief because there was only one CNA on the floor. The family member said there was not enough staff when so many residents needed two person care person care. VIII. Schedule Random dates were provided to the business office manager and to the director of nurses for the licensed nurse and certified nurse aides for both the evening and night shifts. The following was found: 7/3/22 showed two CNAs for the entire shift on evening and one CNA who left at 6:08 p.m. The facility did not provide any time cards for the night shift. 8/9/22 showed one CNA on the night shift. The facility did not provide any time cards for the night shift. 8/15/22 had one CNA who worked on the night shift from 9:58 p.m. to 1:55 p.m. and one CNA who worked from 5:00 a.m. to 7:00 a.m Otherwise, only one CNA for the full night shift. 9/27/22 showed the evening shift had two CNAs and one that finished at 6:00 p.m. which left two CNAs for the evening shift. VIIII. Interviews Licensed practical nurse (LPN) #1 was interviewed on 9/28/22 at 7:45 p.m. She said two nurses worked the floor except on Wednesdays when one nurse had to be responsible for all the facility residents. The LPN said during the day shift there were two CNAs per unit equally for CNAs. She said at night two CNAs assisted with resident's ADLs for the facility. CNA #1 was interviewed on 9/26/22 at 7:30 p.m. The CNA said that she works hall A alone. She said because she worked alone, when she needed help with the mechanical lift, she would ask someone in administration to be the second person. The activity director (AD) was interviewed on 10/4/22 at approximately 10:00 a.m. The AD said that she was a CNA and that at times she was pulled away from her current job to work the floor as a CNA. The director of nurses and the nursing home administrator were interviewed on 10/4/22 at approximately 11:00 a.m. The NHA said the staffing requirements were based on census and the acuity of the residents. She said when the CNA staff had a call off then she pulled from other departments who were also CNAs. She said she tried to replace it within an hour. The DON said that she staffed the halls with two CNAs on C and D halls and one CNA on A hall for both days and evenings. She said he licensed nurses worked 12 hour shifts and had two licensed from 6:00 a.m. to 6:00 p.m. She said then it dropped to one licensed nurse for the entire building from 6:00 p.m. to 6:00 a.m. The NHA said the facility staffed accordingly and believed it was fully staffed. A staff member who preferred to remain anonymous was interviewed on 10/4/22. They said the facility would not increase its staff numbers till the census was up even though staff continue to express that they need more assistance with residents. They said the facility had several residents with high acuity needs but they were not receiving all care needed because there was not enough staff to adequately provide the care. They said some nurses have to worked alone, which was not safe for the residents. They said sometimes one nurse for the entire facility for eight hours. The staff member reiterated that current staffing levels were not safe; residents were falling, wandering unsupervised, and receiving a slower response to cares. The director of nurses was interviewed a second time on 10/5/22 at approximately 9:00 a.m. The DON said she was going to look for more employee time cards, as she said she always ensured there were three CNAs on evenings and two on night shifts. She said the building had a total of 11 residents who need the mechanical lifts, three sit to stand lifts, six residents who wander throughout the facility. A certified nurse aide who wished to stay anonymous was interviewed on 10/5/22. The CNA said that the front hall was tough to get everything done, which included call lights, and residents ready for the day. The social service director (SSD) was interviewed on 10/5/22 at 9:49 a.m. The SSD who was also a CNA said she was pulled from her current job to work as a CNA. She said that when she was pulled, then her job in social services did not get completed. The SSD was interviewed again on 10/5/22 at 12:03 p.m. She said she had heard a CNA say it's lunch time, the resident would have to wait to be changed. The SSD said that should not happen.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** X. Resident #34 A. Resident status Resident #34, age [AGE], was admitted on [DATE]. According to the September 2022 CPO diagnosis included Alzheimer dementia. The 5/23/22 MDS assessment revealed, the resident had severe cognitive impairment with a brief mental status score (BIMS) of two out of 15. She had inattention and disorganized thinking. She required limited assistance with dressing and was independent with all other activities of daily living (ADL). She had no behaviors and did not reject care. She wandered daily which placed her at risk of getting into a potentially dangerous place. She received anti anxiety medication daily. B. Observations On 9/26/22 at 12:00 p.m., the resident was in the hallway and was asking where she was. The staff she asked did not offer redirection. On 9/27/22 at 10:00 a.m., the resident was sitting with registered nurse (RN) #2 at the nurses station. RN #2 did not interact with the resident while she did her computer work. On 9/28/22 at 8:00 a.m., the resident was wandering down the hallway throughout the morning. The staff had minimal to no contact with the resident. The staff ultimately redirected her back to her room. At 3:00 p.m., the resident was in her room awake, alone, and unattended sitting in a recliner. No meaningful activity. On 9/29/22 at 8:15 a.m., the resident was wandering the halls confused and disoriented. At 12:30 p.m., the resident was dressed in the same clothing as the day prior. The resident constantly asked for help. CNA #4 was within close proximity of the resident but did not offer resident assistance. The resident stood alone in the hallway and asked for help multiple times throughout the afternoon. At 2:00 p.m., the resident was listening to a performer sing and play piano in the activities room. On 9/30/22 at 8:40 a.m., the resident was asleep in the room. The resident awakened and escorted to dining room by CNA #5. C. Record review The care plan last updated 6/2/22 identified the resident had impaired cognitive function, impaired thought process and had a diagnosis of Alzheimer's/dementia. Pertinent interventions were to ask yes no questions to determine her needs, and to encourage the resident to make decisions regarding tasks of daily living, and keep the most recent routine consistent and try to provide consistent care givers as much as possible to decrease confusion. There was no documentation to support residents' participation in meaningful activities to address the resident's routines, interests, preferences, and choices to enhance the resident's wellbeing. The physician's admission order dated 6/2/22 read, The resident is not capable of understanding her rights. -The care plan failed to include the resident's target behaviors and pertinent interventions specifically for the resident to address her behaviors. The activity participation for July, August, and September 2022 did not include evidence of attendance. The September 2022 treatment administration records identified target behaviors as: -Constant pacing, wandering, asking the same question over and over. Interventions included to redirect, one to one activities, return to room, activity, toilet, food, fluids, change position, adjust room temperature, backrub, and medication. -Teary eyed, interventions included to redirect, one to one activity, return to room, activity, toilet, food, fluids, change position, adjust room temperature, backrub, and medication. -Withdrawn, interventions included to redirect, one to one activity, return to room, activity, toilet, food, fluids, change position, adjust room temperature, backrub, and medication, -There was no documentation to support residents' participation in meaningful activities to address the resident's routines, interests, preferences, and choices to enhance the resident's wellbeing. D. Staff interviews The activities director (AD) was interviewed on 10/4/22 at 11:40 a.m. The AD said there were minimal activities geared toward residents with dementia. She said in the past, the resident had participated in kick ball and balloon toss. The activities director had no record of attendance or documentation about Resident #34 attendance in activities. The AD said it was a struggle to keep the resident's attention. The AD did offer one-on-one activities for Resident #34. The AD said her and the two assistants did not have dementia training. Based on observations, record review and staff interviews, the facility failed to ensure three (#4, #30 and #34) of five out of 26 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to comprehensively assess and effectively identify person-centered approaches for dementia care for Resident #4, #30 and #34. Findings include: I. Facility policy and procedure The Dementia Care clinical protocol, revised November 2018, was provided by the director of nursing (DON) on 10/3/22 at 4:05 p.m. It documented in pertinent part, For the individual with confirmed dementia, the facility will identify a resident-centered care plan to maximize the remaining function and quality of life. Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Direct care staff will support the resident in initiating and completing activities and tasks of daily living to include bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. II. Resident census and conditions The 9/26/22 Resident Census and Condition form documented 36 residents with 16 residents diagnosed with dementia and 16 residents with a psychiatric diagnosis. III. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the September computerized physicians orders (CPO), the diagnoses included unspecified dementia, psychotic disturbance, mood disturbance, depression, and generalized anxiety disorder. The 6/20/22 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief mental status score (BIMS) of four out of 15. He had inattention and disorganized thinking. He required supervision with dressing and was independent with all other activities of daily living (ADL). He had no behaviors and did not reject care. He wandered daily which placed him at risk of getting into a potentially dangerous place. He received anti anxiety medication daily. B. Resident altercations (cross-reference F600) The facility documentation from 6/28/22 revealed Resident #4 was in another resident's room. Residents #31 heard a resident scream and went to her room. He saw Resident #4 standing in the room so he took Resident #4 by hand to escort him out of the resident's room and into the hallway like the staff had done. Resident #4 said something that Resident#31 did not understand and he responded, We are going down here. Resident #4 swung his arm and Resident #31 blocked it with his left arm. Resident #4 ended up on the floor. Resident #31 had a bruise to his posterior forearm. The facility documentation from 6/30/22 revealed Resident #4 was standing in front of Resident #17's room entrance where he was sitting in his wheelchair. A nurse heard Resident #17 yelling and when she exited the nurses station she saw Resident #4 swing his arm to hit Resident #17. The nurse yelled to Resident #4 to stop. Resident #4 walked away, entered and exited an empty room, and exited down the hallway. The nurse went to escort Resident #4 from the area. Resident #4 shoved the nurse in her left shoulder with his right shoulder as she approached. Another staff member intervened and escorted Resident #4 off the east wing and back to the west wing where his room was located. Resident #17 stated Resident #4 had hit him. A red mark was noted to Resident #17's neck, which faded in a short time. Resident #4 was placed on one-on-one monitoring (during the investigation) and then every 15 minute checks thereafter. C. Behavior documentation The September 2022 behavior monitoring documented five episodes of grabbing, hitting or pushing others, expressing anger or agitation and three episodes of wandering. Progress notes The 6/9/22 health status note documented the resident was awake and wandering on the east and west wings and entering other resident rooms. He was redirected constantly but had poor short term memory. The 6/23/22 nursing progress note documented the nurse was summoned to help separate Resident #4 from another resident. When the Resident #4 was asked to leave the other residents room he became combative with the staff and the other resident. The other resident had a cane and Resident #4 swung at her but did not make contact. The staff member intercepted the swing and the resident hit the staff member. The 7/9/22 general progress note documented the resident had exited through an exit door to the outside and activated the alarm. After several minutes the resident was persuaded to return to the building by staff members. The 8/24/22 health status note documented the resident was moving furniture around in his room causing a skin tear to his right elbow. The resident was unable to state how the skin tear occurred due to his dementia. The 9/14/22 behavior note documented the resident wandered into a female resident's room and she was screaming and said she was scared. A certified nurses aide (CNA) removed the resident from the room and reminded Resident #4 not to go into other resident rooms. The 10/2/22 health status note documented the resident could not be redirected after several attempts. He continued to insist on grabbing items out of the medication cart during count and taking items off of the medication and treatment carts. It documented Ativan (anti-anxiety medication) was given with good results. Care Plan The mood care plan, revised 7/7/22, documented the resident had alterations in mood and behaviors as evidence by outburst. The goal was to have fewer episodes of outburst of anger. Pertinent interventions listed were to administer medications as ordered and monitor/document side effects and effectiveness, anticipate and meet the residents needs, minimize potential for the resident's disruptive behaviors by offering tasks which divert attention, provide a program of activities that is of interest and accommodates resident status, and provide positive reinforcement/praise of the resident's progress/improvements/control in behavior. The dementia care plan, revised 7/7/22, documented the resident may have days where he became physically and/or verbally towards staff and others due to poor impulse control. Pertinent interventions listed were to speak to him in a calm, quiet voice and activities. -The resident's care plan did not have personalized interventions to address his behaviors including wandering into others rooms. IV. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 9/29/22 at 3:52 p.m. He said Resident #4 wandered and tried to hug and kiss other residents and staff. He said Resident #4 had altercations in the past and wandered into other resident's rooms. He said the staff tried their best to keep him out of other resident rooms. CNA #5 said on one occasion Resident #4 swung at him as he attempted to escort him out of a resident's room. He said on one occasion Resident #4 walked into a female resident's room and she started screaming because she was fearful of him. So, he escorted Resident #4 out of her room. He said they were doing every 15 minute checks and some of the residents have a stop sign across their door. Licensed practical nurse (LPN) #1 was interviewed on 9/29/22 at 4:07 p.m. She said Resident #4 had dementia and if you argued with him he would get aggressive. She said the staff tried to redirect him by giving him something to read or write. She said she had only been at the facility for a month and had not seen him in any altercations. She said sometimes Resident #4 would wander into other resident rooms and the other residents would get angry and ask the staff to remove him from their room. She said Resident #4 was on every 15 minute monitoring. The activity director (AD) was interviewed on 10/4/22 at 4:11 p.m. She said Resident #4 liked to go outside and watch the birds. She said she had very little dementia training. She said she had experience from her previous job as an activity assistant. She said there were minimal activities for residents with dementia and there was no current dementia program. She said the activities were not person center, but were for all residents to attend. The executive director (ED) was interviewed on 10/4/22. She said Resident #4 wandered into other resident rooms because he liked to visit. She said she was not sure why the other residents feared him. She said the staff was behind on their computer based dementia training. She said the computer based dementia training was not specific to activities. She said person centered activities would help with wandering. She said the facility would be opening a memory care unit, which would help residents have a sense of belonging and an activity program to give them a sense of well being. She said the unit would help with residents who wander and disrupt activities and meals. She said the facility should have activity supplies to engage the dementia residents. The ED was interviewed again on 10/5/22 at 4:24 p.m. She said dementia care was not discussed in the quality assurance/performance improvement (QAPI) meetings. V. Resident #30 A. Resident status Resident #30, age [AGE], was admitted to the facility on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses included repeated falls, Parkinson's disease, neurocognitive disorder with Lewy bodies, cognitive communication deficit, difficulty in walking, muscle weakness, and a need for assistance with personal care. According to the 8/27/22 minimum data set (MDS) assessment, a brief interview for mental status (BIMS) was not conducted. According to the staff assessment for mental status, the resident had severe impairment for making decisions regarding tasks of daily life. Resident #30 had a short and long term memory problem. The assessment identified the resident displayed inattention and disorganized thinking. The MDS assessment indicated Resident #30 required limited assistance of one person for dressing, toileting and personal hygiene. He required supervision with set up for bed mobility transfers and eating. According to the MDS assessment the resident was independent in walking in his room and locomotion on and off the unit B. Observation Observations were conducted between 9/26/22 and 9/30/22, and again on 10/3/22 and 10/4/22. Observations identified long periods of the resident sitting or standing near the nursing station without an offer for an activity. The resident was observed sitting in his room without offers of an activity, including an offer to put western music on for him to listen to. Observation did identify staff holding his hand to walk down the halls, and in one instance away from a resident's room that was being mopped on 9/30/22 at 10:46 a.m. C. Record review The impaired cognitive function care plan, initiated on 2/3/22 read resident had impaired thought processes related to dementia. Interventions directed staff to: -Communicate with the resident, the family and caregivers regarding residents capabilities and needs; and, -Present just one thought, idea, question or command at a time. The 2/3/22 CPO read Resident #30 was not capable of understanding his rights due to dementia. The psychosocial care plan, initiated on 2/14/22, identified Resident #30 was dependent on staff for meeting his emotional, intellectual, physical, spiritual and social needs related to his cognitive deficits and disease process. Interventions included: -All staff to converse with the resident while providing care; -Encourage ongoing family involvement; -Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family; -Introduce the resident to residents with similar background, interests and encourage and facilitate interaction; -Invite the resident to scheduled activities; -Provide the resident with an activity calendar; -The review of resident activity needs with the family/representative; -The resident enjoys country music; -The resident enjoys socializing with friends, family and staff; -The resident enjoys westerns; -The resident needs assistance/escort to activity functions; -The resident prefers activities which do not involve overly demanding cognitive tasks; and, -Thank the resident for attendance at the activity function. The wandering care plan, initiated on 3/22/22, read Resident #30 known to wander in other residents' rooms. The care plan directed all staff to redirect the resident when he wandered into other resident rooms. The 5/4/22 elopement wanderer care plan directed staff to distract residents from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. sitting with other residents. The alteration in cognitive status, initiated on 8/30/22, read resident #30 had delirium due to his Lewy body dementia. Interventions included: -Ensure the resident's toileting routine was enforced; -Resident #16 had an improved understanding when staff used short, simple sentences; According to the intervention, staff should speak slowly and clearly to the resident, they should not act rushed and identify self with their name at each contact; -Provide medications to alleviate agitation as ordered by the physician; and, -Repeat questions if needed, allowing adequate time for response. The 8/17/22 CPO identified the resident had an order for a wanderguard. The 8/12/22 CPO identified the resident had an order for a lorazepam for anxiety. The 8/29/22 health status note read attempted to enter another resident's room but was easily redirected. The September 2022 medication and treatment administration record MAR/TAR identified monitor behavior pacing, agitation, anxiety every shift for lorazepam. The 9/22/22 CPO read Resident #30 may participate in all activities and social functions. The 8/29/22 health status note read Resident #30 attempted to enter another resident's room but was easily redirected. D. Staff interview Certified nurse aide (CNA) #9 was interviewed on 10/3/22 at 10:11 a.m. She said Resident #30 usual routine was to sit in his reclining chair in his room and take a nap and his wife often visits. She said his increased behaviors such as wandering often worsen around dinner time. CNA #9 said staff tried to redirect Resident #30. She said staff encourage him to follow them or stay near staff. She said he had short attention and needed activities that were engaging but were short in duration. She said staff could benefit from dementia, specifically behavior interventions for wandering and learn what it was like to be in their shoes referring to the perspective of a resident with dementia. The CNA said Resident #30 took a lot of staff's time. She said staff could use more help redirecting Resident #30 or just keeping him busy. CNA #9 said other residents could become very frustrated with him because of the intrusion into their rooms. She said if Resident #30 was occupied instead of wandering, it would take a lot of stress off the staff and cognitively intact residents. The social service director (SSD) was interviewed on 10/3/22 at 4:40 p.m. The SSD said Resident #30 would often wander into several residents ' rooms including Resident #7 and Resident #35. She said the nursing staff tried to redirect him. She said the facility has implemented stop signs. She said the stop signs had helped him from going into Resident #7's for as much. The SSD said he liked to rest in his room and listen to western music, sit by the nurses station and talk to staff and residents. She said Resident #30 had behavior tracking on the MAR/TAR for his psychotropic medication target for his anxiety. A staff member who requested to remain anonymous, was interviewed on 10/4/22. They said the staff need training on redirecting behaviors. They said they had seen staff try to redirect Resident #30 out of a resident room by holding his upper arm which would then escalate his behaviors. They said staff needed to just have Resident #30 hold their hand and would go where they wanted it to go. The activity director (AD) was interviewed on 10/04/22 at 9:01 a.m. The AD said activities helped residents calm down and helped with wandering, when they were lost, helped them to be with somebody. The AD said Resident #30 was fixated on looking for his wife. She said if he was brought to an activity or wandered in for a moment, she would mark on his participation record that he was present for the activity whether he engaged in the activity or not. The AD said Resident #30 liked to listen to music in his room. She said he also enjoyed sitting at the nursing station and talking to people. The AD said activities took him for walks and gardening. She said he was a farmer and liked to garden. She said activity she did not recall when the last time Resident #30 had gone out to garden and water the flowers. She said it had not been gardening recently. She said she did not know if watering was identified on the attendance records. The AD said he liked to play ball toss. She said she did not know when he last played ball toss. She said she tried to put in a note when Resident #30 did a specific activity. She said needed to improve the one to one program. She said a one to one program that was individualized for the resident and would consist of a ten minute visit, three times a week. The AD said Resident #30 was not on a one-to-one program but he could benefit from one. She said needed to improve the one-to-one program. She said she did not know why he was not on a one to one program. VI. Additional interviews from residents and family interview Resident #7 was interviewed on 9/28/22 at 12:26 p.m. She said she was very uncomfortable when wandering residents entered her room. She said some of the confused residents tried to kiss her or were aggressive. She said she said there was a female resident that liked to sit on her bed and would not leave and could become aggressive. She said Resident #30 walked in her room and could become aggressive if she told him to leave. She said he could be more aggressive with staff. He became upset with her. She said another male resident, Resident #4 often wanted to come up to her and kiss her. She said she had a past history with trauma related men being aggressive or attempting to advance themselves on her. She said it made her want to have a flight or flight response, and when she wanted to flight, she had nowhere to go so she would fight if she had to. She said staff put up the stop sign across her to help stop the wandering in her room. She said the wandering in her room was a little bit better. Resident #35 was interviewed with her husband on 9/28/22 at 10:40 a.m. The husband of Resident #35 said he had seen Resident #30 become aggressive with staff. She said staff had to remove him from rooms forcefully. He said it was forceful within reason. He said however when they place their hands under his upper arm and shoulder, it seems to upset him more and he gets more aggressive with staff. The husband said he had removed Resident #30 from his wife's room. Resident #35 said they were nice to him when he came into their room but she would prefer the wandering residents not come into her room because she never knows the confused residents would do. The husband said one time their son was visiting from out of town and they were having a special family dinner together. He said Resident #30 continued multiple times to entered Resident #35's room and disrupt their meal. He said his son finally had to take Resident #30 to the nurses stations and told the staff that families should not have to handle the problem of resident's wandering into rooms, it should be the staff's problem to handle it. Resident #35 said she just wanted more privacy and for the wandering residents not to come into her room. She said no staff would want people to continue to wander in their rooms. The husband said they used to have a stop sign across the door of the room but it was taken down when the inside of the facility was being painted. He said staff never hung the sign back up. He said the stop signs were still not enough however, to keep the other residents out of the room. He said staff had to watch the wanders all the time. The family member said Resident #35 has long waits for activity of daily living (ADL) assistance because staff have to spend so much time with the wandering residents (Cross-reference F725 staffing). VII. Resident group meeting The resident group interview was conducted on 9/28/22 at 1:35 p.m. The group consisted of six alert and oriented residents (#3, #20, #22, #31, and #33) selected by the facility. The residents stated the following: There were residents who would wander into their rooms without permission. The residents wander in during all times of the day or night, even when they were in the bathroom. VIII. Dementia training The staff online training program course description for communicating with dementia residents, challenging behaviors with dementia care, and managing aggressive behaviors, was provided by the facility on 10/5/22. The course description for communicating with dementia residents read the course would teach the staff how to: Understand the person with dementia by knowing them as an individual and recognizing common speech patterns; how persons with dementia use behaviors for communicating discomfort; and the communication strategies you can employ to ensure the person received your message. The course description for challenging behaviors with dementia care read: Individuals with Alzheimer's disease and Related Disorders often have challenging behaviors. It is important to know all of that behavior has meaning. Although there is no way to prevent all-in-one behaviors there are ways to decrease their occurrence. The course description for managing aggressive behaviors the course would teach the staff how to: Use strategies and techniques to reduce a person's aggressive aggression. In this course you will learn ways to recognize, prevent, and manage aggressive behaviors to protect yourself and others. -However, not all staff received training on dementia care (Cross-Reference F943 abuse, neglect and exploitation training). IX. Lack of dementia care training A. Staff interview CNA #3 was interviewed on 9/28/22 at 9:50 a.m.The CNA said staff had annual training of dementia through a computer based training program. She said the online program offered tips on how to interact with residents with dementia. A staff member who requested to remain anonymous, was interviewed on 10/4/22. They said the facility had a lack of effective dementia training for all staff with behavior interventions. They said staff needed more specialized training to work with dementia residents. They said staff need to know how to interact with residents. They said they have seen staff stressed when trying to continue to manage the wandering residents' behaviors. They said they have seen staff throw up their hands and say I don ' t have time for this in response to dementia resident continuous needs. They said the wandering residents always needed to be busy unless they were medicated. They said the facility needed more activities for dementia residents. They said the activities that were offered were geared for highly functioning leveled residents and were not appropriate for dementia residents. The staff member said staff did not have the staffing needed to handle the acuity needs of the residents (cross-reference F725 staffing). They said there were times that there was only one nurse in the facility in the evenings, which was a critical time for residents with sundowning and wandering behaviors. They said many staff did not feel supported by management with staffing and training concerns. The SSD was interviewed on 10/5/22 at 9:31 a.m. The SSD said the facility was planning to open a memory care unit for dementia residents in the near future. The SSD said the memory care unit would be beneficial for residents like Resident #7, that did not want to be approached by wandering residents. The SSD said the unit would be more specialized to meet the needs of dementia residents including dementia appropriate activities. The SSD said the memory care unit would have an activity assistant full time to work with the dementia residents. The SSD said dementia appropriated activities should occur if a resident was in a memory care unit or not. She said staff should be able to accommodate each resident's individual needs. The activity director (AD) was interviewed on 10/4/22 at 9:01 a.m. The AD said she received her guidance on dementia care from the NHA, plus she was often pulled away from her AD role so work the floor as a CNA (Cross-reference F725 staffing.). The NHA and the DON were interviewed on 10/4/22 at 2:21 p.m. The DON said staff should always be patient with residents, never raising their voice. She said staff's approach should be personalized to the individual resident. The DON said when staff needed to redirect a wandering resident, staff should ask the resident to hold their hand and come with them. She should never hold the upper arm of a resident. She said that approach could create a negative response.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #34 A . Resident status Resident #34 was admitted on [DATE]. According to the September 2022 CPO diagnosis included Alzheimer's disease, anxiety, and depression. The 9/5/22 MDS assessment showed the resident had severe cognitive impairment with a score of two out of 15 on the brief interview for mental status (BIMS). The resident required limited assistance with activities of daily living. She had no behaviors and did not reject care. She wandered less than which placed her at risk of getting into a potentially dangerous place. She received anti anxiety, and an antidepressant medication daily. B. Record review The 6/7/22 care plan identified the resident had an alteration in mood and behavior related to depression and anxiety. Pertinent interventions listed were to administer medications as ordered by the physician, monitor side effects and effectiveness, and assist the resident in developing/provide the resident with a program of activities that was meaningful and of interest and group exercise. Encourage and provide opportunities for exercise, physical activity. -The care plan failed to document the target behaviors and what non-pharmaceutical approaches were to be used. The September 2022 CPO documented the following: -Fluoxetine HCL capsule 20 mg by mouth once time a day for depression with a start date of 6/23/22; -Alprazolam 0.5 mg by mouth every two hours as needed for anxiety. Start date of 8/19/22. Review of the medication administration record (MAR) from 8/19/22 to 10/4/22 revealed the resident was administered the Alprazolam (brand name Xanax) PRN nearly every day at least one time a day and 18 times she received it twice and four times received it three times a day. Although there were target behaviors documented in the plan of care on 6/7/22 such as constant pacing, wandering and asking the same question over and over, there were not any non-pharmacological interventions documented in the resident's progress notes. The original order for the Alprazolam was received on 6/2/22 at 0.25 mg but was increased on 8/19/22 to 0.5mg. The June 2022 MAR showed the mediation was administered daily and on 13 days it was given twice and once three times. -Review of the progress notes revealed the physician failed to document a rationale for the continued use of the PRN Alprazolam after 14 days. -The medical record did not have signed consents for either the Fluoxetine or the Alprazolam. C. Staff interview The social service director (SSD) was interviewed on 10/4/22 at 9:49 a.m. The SSD reviewed the record and confirmed the signed consents were not completed. She said the resident was admitted to the facility on the Alprazolam. She said that it helped calm her down. She said that the resident was severely cognitively impaired. She said she wandered and she asked the same question over and over. She said that the resident needed to be redirected. She said anytime the as needed medication was administered then a non-pharmaceutical should be attempted. The anti-depressant was added, as the resident was showing signs of sadness, which she no longer was showing. D. Facility follow-up The informed consent for the use of the Fluoxetine or the Alprazolam were signed by the power of attorney on 10/4/22. Based on record review and interview, the facility failed to ensure the facility failed to ensure that residents were free of unnecessary psychotropic medications for three (#4, #28 and #34) of six residents reviewed for unnecessary medications out of 26 sample residents. Specifically, the facility failed to ensure: -As needed (PRN) psychoactive medications were discontinued after 14 days for Resident #28, Resident #34, and Resident #4 without a documented rationale; -Consent forms were signed for Resident #34; and, -Non-pharmacological interventions were utilized prior to the administration of the PRN psychoactive medications for Resident #34, #28 and #4. Findings include: I. Resident #28 A. Resident status Resident #28, age [AGE], was admitted to the facility on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included unspecified dementia, altered mental status, depression, repeated falls, mood disturbance and anxiety. The 5/22/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for a mental status score of two out of 15. She was rated as being independent to supervision only with her activities of daily living (ADLs). She was coded as having no behavior symptoms, she did not reject care and that she did not wander. She was on antianxiety and antidepressant medications. B. Record review The care plan initiated 5/9/22, and revised on 5/25/22, identified the resident with chronic anxiety, but did not identify if any anti-anxiety medications were being used. It also did not include any behavior monitoring for the target behaviors of feeling anxious, agitated, and irritable. -The care plan did not include person-centered individualized non-pharmacological interventions to attempt, prior to the use of the PRN medication. The September 2022 electronic medication administration record (eMAR) documented a diazepam 5 mg tablet every eight hours as needed for anxiety. The medication was started on 5/10/22. Review the September 2022 medication administration record (MAR) showed the resident received diazepam: at least one dose 23 out of 30 days. Two doses were given on nine out of 30 days. -There were not any non-pharmacological interventions for anxiety documented in the resident's progress notes. -Review of the progress notes revealed the physician failed to document a rationale for the continued use of the PRN diazepam after 14 days. C. Observations On 9/26/22 at 11:58 a.m., the resident was wandering the hallways with no meaningful activities. On 9/28/22 at 3:50 p.m. the resident was in the hallway crying while on her personal cell phone. She was near the nursing station on 9/30/22 at 12:25 p.m. crying, wanting extra blankets. D. Staff interviews The social services director was interviewed on 10/5/22 at 9:22 a.m. She stated that anxiety, crying, and hyperventilating were some target behaviors that the resident would exhibit for diazepam administration. She acknowledged that those behaviors and the non-pharmacological interventions should be on the resident's care plan. She reported that the psychotropic drug committee meets monthly with the pharmacist, physician, nursing home administrator (NHA) and the director of nursing (DON). II. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the September computerized physicians orders (CPO), the diagnoses included unspecified dementia, psychotic disturbance, mood disturbance, depression, and generalized anxiety disorder. The 6/20/22 minimum data set (MDS) assessment revealed, the resident had cognitive impairment with a brief mental status score (BIMS) of four out of 15. He had inattention and disorganized thinking. He required supervision with dressing and was independent with all other activities of daily living (ADL). He had no behaviors and did not reject care. He wandered daily which placed him at risk of getting into a potentially dangerous place. He received anti anxiety medication daily. B. Record review The anti-anxiety medication care plan, revised 6/20/22, documented the resident used the medication for adjustment issues, anxiety, and periods of agitation. Pertinent interventions listed were to administer medications as ordered by the physician, monitor side effects and effectiveness, and attempt non drug approaches to assist in redirecting behavior. The mood care plan, revised 7/7/22, documented the resident had alterations in mood and behaviors as evidence by outburst. Pertinent interventions listed were to administer medications as ordered and monitor/document side effects and effectiveness, anticipate and meet the residents needs, minimize potential for the resident's disruptive behaviors by offering tasks which divert attention, provide a program of activities that is of interest and accommodates resident status, and provide positive reinforcement/praise of the resident's progress/improvements/control in behavior. The September 2022 CPO documented, Lorazepam (anti-anxiety medication) give 0.5 mg (milligrams) by mouth every 4 (four) hours as needed (PRN) for anxiety times 90 days. The medication was started on 9/18/22 for 90 days. Review of the medication administration record (MAR) from 9/18/22 to 10/4/22 revealed the resident was administered the Lorazepam (brand name Ativan) PRN on 9/18/22 x two doses, 9/19/22 x two doses, 9/20/22 x two doses, 9/21/22, 9/22/22 x two doses, 9/23/22 x two doses, 9/24/22 x two doses, 9/25/22, 9/26/22 x two doses, 9/27/22, 9/28/22, 9/29/22, 10/1/22 x two doses, 10/2/22, and 10/4/22. -There were not any non-pharmacological interventions documented in the resident's progress notes. -Review of the progress notes revealed the physician failed to document a rationale for the continued use of the PRN Lorazepam after 14 days. C. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/29/22 at 4:07 p.m. She said Resident #4 would get aggressive and wander into other resident's rooms. She said if he could not be redirected, he would be given the PRN Lorazepam. She said PRN Lorazepam should be given until the ordered stop date. The pharmacist was interviewed on 10/4/22 at 4:48 p.m. She said she visited monthly and sat in the quality assurance/performance improvement (QAPI) and the psychotropic meetings. She said Resident #4 had been on Lorazepam since June 2022 and the PRN Lorazepam was started on 9/18/22. She said she did not advise a stop date after 14 days because he was already taking it routinely.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and infection for one out of two units. Specifically, the facility failed to: -Ensure housekeeping staff cleaned high-touch surfaces in resident rooms and follow manufacturer surface contact time during routine daily cleaning; -Ensure housekeeping staff followed the appropriate procedure when cleaning resident rooms and bathrooms; and, -Implement appropriate hand hygiene with glove changes. Findings include: I. Professional standards The Centers for Disease Control and Prevention (2020) Preparing for COVID-19 in Nursing Homes, updated 11/15/21, retrieved on 10/11/22 from: https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html/, revealed in part: For environmental cleaning and disinfection: develop a schedule for regular cleaning and disinfection of shared equipment, frequently touch surfaces in resident rooms and common areas. Clean high-touch surfaces at least once a day or as often as determined is necessary. Examples of high-touch surfaces include: pens, counters, shopping carts, tables, doorknobs, light switches, handles, stair rails, elevator buttons, desks, keyboards, phones, toilets, faucets, and sinks. II. Product information The Disinfectant surface contact time, retreived on 10/11/22 from: https://www.spartanchemical.com//globalassets/sharepoint/product-literature--documentation---epidocuments/efficacy-bulletins/x-effect-efficacy-bulletin.pdf, revealed the surface must remain wet for 10 minutes. III. Observations On 9/29/22 at 9:40 a.m., housekeeper (HK) #1 was observed preparing to enter room [ROOM NUMBER]. She used alcohol based rub (ABHR) and donned gloves. She removed a white rag and a red rag from the tub of disinfectant on top of the HK cart with a surface contact time of 10 minutes. She removed the toilet brush and the toilet bowl cleaner. She entered the bathroom, lifted the toilet seat and poured the toilet bowl cleaner into the toilet. She used the wet white rag to clean the top of the sink, the inside, the sides and bottom. She used the toilet brush to clean the toilet bowl and then placed it back into its holder. She used the wet red rag to clean the rim of the toilet, the side, the base, the seat, the lid, and the toilet tank. She used the same red rag to wipe down the over the toilet seat from top to bottom. She emptied the trash and placed the trash, the two rags, the toilet brush, and toilet cleaner back on the cart. She removed her gloves but did not use ABHR. She donned clean gloves. At 9:44 a.m. the sink and toilet were already dry. She emptied the room's trash and placed it on the cart. She removed a purple rag from the disinfectant tub. At 9:48 a.m. she used the purple rag to wipe down the over bed table from top to bottom. She placed the soiled rag into the hanging trash bag on the side of the cart. She removed a mop pad from the disinfectant in the mop bucket and the mop handle. At 9:50 a.m. she dropped the mop pad onto the floor and placed the mop handle on top of it. She mopped the room and pushed the debris to the room entrance and used a dustpan with a hand held brush to pick it up. She used a clean mop pad to mop the bathroom. At 9:54 a.m. the room's floor was dry. She placed the soiled mop pad from the bathroom onto the cart as well as the mop handle. She removed her gloves and placed a wet floor sign in the doorway. She did not use ABHR before pushing her cart to room [ROOM NUMBER]. -HK #1 failed to clean and disinfect highly touched areas such as door knobs, light switches, closet handles, night stand, call light, television remote, and the bed controller. She failed to perform hand hygiene after removing her gloves. She failed to follow the manufacturer's instructions of a 10 minute kill time. She failed to clean the toilet from top to bottom and clean to dirty. HK #1 was observed on 9/29/22 at 9:58 a.m. preparing to enter room [ROOM NUMBER]. She donned gloves and removed a wet rag from the disinfectant and a dry rag. She unlocked the cart and removed the toilet brush and the toilet bowl cleaner. She entered the bathroom, lifted the toilet seat and poured the toilet bowl cleaner into the toilet. She used the wet rag to clean the inside of the sink, the top of the sink, and the sides. She used the dry rag to immediately dry the sink. She used the toilet brush to clean the toilet bowl. She used the same wet rag to clean the toilet rim, sides of the toilet, under the seat, the seat, the lid, and then the toilet tank. She emptied the trash and placed the trash, the soiled rag, the dry rag, the toilet brush, and toilet cleaner back on the cart. She did not remove her gloves and removed a dry rag from the cart. She used the dry rag to dust the bedside table, the head board, the front of the bedside table, the top of the dresser, the bottom of the desk chair and the recliner. She placed the dry rag on the cart and doffed her gloves. She used ABHR and donned clean gloves. She removed the mop pad and mop handle from the cart. At 10:04 a.m. she dropped the mop pad onto the bedroom floor and placed the mop handle on it and began to mop the room. At 10:07 a.m. the floor was beginning to dry. She used a clean mop pad to mop the bathroom. She removed the soiled mop pad from the handle and placed both of them on the cart. She placed a wet floor sign in the doorway. She removed a hydrogen peroxide wipe from the cart and cleaned the door knob and the light switch. She removed her gloves but did not perform hand hygiene. -HK #1 failed to clean and disinfect highly touched areas such as closet handles, night stand, call light, television remote, and the bed controller. She failed to remove her gloves and perform hand hygiene after cleaning the bathroom. She failed to follow the manufacturer's instructions of a 10 minute surface contact time. She failed to clean the toilet from top to bottom and clean to dirty. IV. Staff interviews HK #1 was interviewed on 9/29/22 at 10:09 a.m. She said she had only been working as a HK for two months. She said prior to that she was the facility hairdresser. She said she did not know what the surface contact l time was for the disinfectant. She said she had not received any training on how to clean and disinfect a room and had not yet taken the computer based training. She said she had not received any hand hygiene training and did not know what high touch areas were. The housekeeping supervisor (HKS) was interviewed on 9/29/22 at 10:15 a.m. She said she did not know the disinfectant surface contact time was 10 minutes. She said that was too long to keep the surface wet. She said since the contact time was 10 minutes, HK #1 should not have used a dry rag to dry the surfaces. She said she did not provide one-on-one training with the housekeeping staff. She said the computer based training was recently restarted and staff were trying to catch up on their required training. She said she did room checks but did not watch the housekeepers clean a room. She said she did not know the toilet should be cleaned from top to bottom and from clean to dirty. She said she had not received any training when she took over the HKS position. She said if the rooms were not cleaned properly, the facility could have an outbreak of any communicable diseases. She said she received training on cleaning high touch areas but did not pass the training to her staff because she figured it was common sense. She said she would immediately change disinfectants to a one minute surface contact and train her staff on proper cleaning techniques and proper hand hygiene. The executive director (ED) was interviewed on 10/4/22 at 9:52 a.m. She said the facility should not have been using a disinfectant with a 10 minute surface contact time because it would be difficult to keep the surface wet for that long. She said they would change the disinfectant to a one minute surface contact time solution. She said all housekeepers should be cleaning from top to bottom and clean to dirty. She said all high touch areas should be cleaned at least daily with the room cleaning and twice daily in the common areas or more frequently in an outbreak.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0943 (Tag F0943)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on record review and interviews, the facility failed to ensure all staff had current abuse and dementia care training. Specifically, the facility failed to ensure five out of five licensed nurses and CNAs reviewed within the previous year received dementia management training and abuse prevention training. Findings include: I. Record review Staff annual training for the selected nursing staff (CNAs and licensed nurses) were requested from the director of nursing on 10/3/22 at approximately 2:30 p.m. The facility was unable to provide the annual training which included, abuse, neglect and exploitation training and dementia care training. II. Staff interview The director of nurses was interviewed on 10/5/22 at 9:00 a.m. She said she did not have the training records and competency checklists. She said the assistant director of nursing (ADON) was no longer employed and she could not find the employee training logs and competency checklists. The DON said the abuse training and dementia training was completed on a computerized program, however, no logs could be found for completion for the selected staff. She said she would start to put a plan in place to ensure staff were completing the training. The corporate nurse was interviewed on 10/5/22 at 6:29 p.m. The corporate nurse said dementia and abuse training were required courses on the computerized training system. She said the names which were provided, they were unable to locate the records which showed they received the training.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interviews and record review, the facility failed to ensure nurse aides received the required number of annual in-service training hours to ensure continued competence for four of four staff reviewed. Specifically, the facility failed to ensure certified nurse aides (CNA) #1, #5, #8 and #9 received 12 hours of continuing education annually. Findings include: I. Record review Staff annual 12 hour training for the selected nursing staff CNA #1, #5, #8 and #9 were requested from the director of nursing on 10/3/22 at approximately 2:30 p.m. The facility was unable to provide the annual training which included abuse, neglect and exploitation training and dementia care training, nutrition, accident hazards, emergency preparedness and dignity. II. Interviews The director of nurses was interviewed on 10/4/22 at 4:00 p.m. She said she did not have the training records and competency checklists. She said the assistant director of nursing (ADON) was no longer employed and she could not find the employee training logs and competency checklists. She said that she was actively alerting staff to start the training on the computerized system.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, staff education, staff competencies, and facility based risk assessments. Findings include: I. Record review The facility assessment was last reviewed on 4/8/22 by the nursing home administrator (NHA), director of nurses, and the interdisciplinary team. The facility assessment failed to include the following: -Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs are met for all new and existing staff; -Include staff trainings/education necessary to provide the level and types of support and care needed for the resident population; -Identify facility resources needed to provide competent resident support during day to day operations and emergencies; and, -Include the facility-based and community-based risk assessment, utilizing an all-hazards approach. II. Staff interviews The nursing home administrator (NHA) was interviewed on 10/5/22 at 6:40 p.m. The NHA said that she and the interdisciplinary team developed the facility assessment. The NHA reviewed the facility assessment and confirmed that although the assessment had some staff training, specified, however, dementia care and emergency preparedness were not included. The NHA said the facility-based risk hazards for their facility were fire, chemical spill and high winds. The NHA confirmed the risk hazards were not part of the facility assessment. The NHA said not all of the resources which the facility utilized were on the facility assessment or direction where the contracts were maintained. Although some staff competencies were on the facility assessment, abuse, change of condition, oxygen, mechanical lift, and nutritional services were some not on the assessment.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and implement an effective system to identify facility concerns or address need for quality improvement in their QAPI program. Findings include: I. Facility policy The Quality Assurance Performance Improvement (QAPI) policy, updated February 2020, was provided by the nursing home administrator (NHA) on 9/26/22. The policy documented in pertinent part, This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven qapi program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI program are to: -Provide a means to measure current and potential indicators for outcomes of care and quality of life; -Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators; -Reinforce and build upon effective systems and processes related to the delivery of the quality care and services; and, -Established system through which to monitor and evaluate corrective actions. The QAPI Committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct the QAPI functions, and the activities of the QAPI committee. The QAPI Plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: -Tracking and measuring performance; -Establishing goals and thresholds of performance measurement; -Identifying and prioritizing quality deficiencies; -Systematically analyzing underlying causes of systemic quality deficiencies; -Developing and implementing corrective actions or performance improvement activities; and, -Monitoring or evaluating the effectiveness of corrective actions/performance improvement activities and revising as needed. The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. II. Cross-referenced citations affecting quality of care identified during the facility's recertification on 10/5/22. A. F689, accident hazards The facility failed to ensure the resident environment remained as free of accident hazards as possible. This deficiency was cited at an K scope, immediate jeopardy at a pattern, for failure to ensure staff were prepared for a potential threat of fire due to lack of fire training and supplement oxygen management. Additional accident/hazards failures were identified related to fall prevention. B. F692, nutrition services cited at a G scope of severity, actual harm, isolated. C. F690, failures related to catheter care cried at a G scope, actual harm, isolated. D. F585, failure to respond to grievances of the resident council and individual residents, cited at E scope, potential for more than minimal harm, pattern. E. F600, failure to prevent abuse, cited at D scope, potential for more than minimal harm, isolated. F. F641, failure to have an accurate minimum data set (MDS) assessment, cited at an E scope, potential for more than minimal harm, pattern. G. F695, failures relating to respiratory services, cited at an E scope, potential for more than minimal harm, pattern. H. F725, failure to have adequate nursing staffing, cited at E scope, potential for more than minimal harm, pattern. I. F758, failures with unnecessary medications, cited at E scope, potential for more than minimal harm, pattern. J. F880, infection control failures, cited at E scope, potential for more than minimal harm, pattern. K. F882, failure to have a qualified infection preventionist, cited at F scope, potential for more than minimal harm, facility wide. L. F943, failure to have abuse and neglect training, cited at E scope, potential for more than minimal harm, pattern. M. F947, failure to have required inservice training, cited at an E scope, potential for more than minimal harm, pattern. III. The facility failed to self identify effective systems or need for quality improvement in their QAPI program. The NHA was interviewed on 10/5/22 at 4:23 p.m. She said the QAPI committee met monthly to continuously improve processes, meet standards and make sure not to miss anything. The NHA said all managers, the medical director, therapy service, the pharmacist, and the registered dietitian, participated in the monthly QAPI meeting. The NHA said during the meeting, the committee reviewed fire drills, facility plant concerns, safety meetings and resident council minutes, and any newly identified workmens' compensations concerns. She said the QAPI committee reviewed old business concerns, and status of new hired and terminated staff. The NHA said the committee discussed dietary and resident care conference concerns. She said the committee looked at medication utilization and new pharmacist processes interventions. The NHA said the QAPI committee also reviewed any breakdowns in departments such as turnover and infection control concerns. The NHA said the QAPI committee used various sources of data to identify problems for improvement including past surveys, the [NAME] quality indicator report, staff schedules, and clinical reports. She said data was collected weeking and graphed for review. The NHA said the committee then reviewed the generated findings and outcomes. She said the QAPI committee reviews additional input from family and resident satisfaction surveys. The NHA said when a concern was identified, the committee attempted to find the root cause using the Five whys method to find the breakdown. She said the committee used audits and education to sustain systematic changes. The NHA said the QAPI committee did not identify concerns with fire drills or training, even though the drills were reviewed during QAPI. The NHA said the management and delivery of oxygen was not identified as a concern or was reviewed in QAPI. The NHA said the oxygen management process would improve. The NHA said the facility would implement a system to monitor through rounding and audits. She said the committee would review the findings to identify the system breakdown and discuss ways to improve the process. The NHA said falls were reviewed in QAPI. She said the committee reviewed any identified fall trends, the type of the fall occurrences, residents with multiple falls, locations of the falls, and any interventions incorporated. The NHA said the committee also reviewed the root cause of the falls. The NHA said weight loss concerns were discussed in QAPI in prior months and their plan was to implement audits related to nutrition documentation and processes, however the audits were incomplete. She said the director of nursing (DON) was to complete the records but she has had to work as a floor nurse too often to do the audits. The NHA said staffing patterns, turn-over and open positions were reviewed in QAPI. She said hiring additional staff was determined based on the census. She said the facility could hire more staff as they increased the census. The NHA said staff training has not been reviewed in QAPI. She said staff competencies were reviewed in March 2022. The NHA said the process for grievances was not reviewed in QAPI, only the actual identified concerns. The NHA said infection control was reviewed in QAPI. She said the committee reviewed trends of infections, illness related to the season, county and community levels, and identified transmission-based infections. The NHA said abuse was reviewed in QAPI. She said the committee reviewed any abuse allegations and investigations. She said the committee discussed interventions to prevent abuse. She said most of the QAPI review on abuse had been related to wandering residents with dementia. She said the facility incorporated activity sorting buckets and stop signs of resident room doors. The NHA said the committee identified a need for a new MDS coordinator to improve MDS accuracy. The NHA said psychiatric medications have been discussed with the pharmacist. The NHA said the pharmacist informed the committee that all prn meds needed to have a stop date. She said there had been a lack of response by the physicians so the committee would initiate the stop dates if the physicians would not. The NHA said additional identified the above (cited) concerns had not been reviewed in the QAPI committee in recent months. The NHA said the facility needed to implement changes in their QAPI process. She said the QAPI committee needed to work on how the committee identified concerns. She said the QAPI structure needed to change. The NHA said the committee needed to focus on how they identify concerns; how they implement the changes; how the facility documented identified issues, and how the committee evaluates and reevaluates the identified changes and processes. The NHA said QAPI needed to tighten its systems.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interviews and record review, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all 36 residents, including four who were currently on antibiotic therapy currently residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified ICP involved with the facility's infection prevention and control program. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/23/22; retrieved on 10/6/22, from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control- recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2 F2019-ncov%2Fhcp%2Flong-term-care.html; read in pertinent part; This guidance is applicable to all U.S.settings where healthcare is delivered (including nursing homes). Nursing homes: Assign one or more individuals with training in ICP to provide on-site management of the IPC Program. Smaller facilities should consider staffing the IPC program based on the resident population and facility service needs identified in the IPC risk assessment. The CDC, Nursing Homes (long-term care facilities) Infection Preventionist (IP) Training, last reviewed 6/10/2020; retrieved on 10/6/22 form: https://www.cdc.gov/longtermcare/training.html; read in pertinent part: The nursing home infection preventionist training course is designed for individuals responsible for infection prevention and control (IPC) programs in nursing homes. The course covers core activities of effective IPC programs; and recommended IPC practices to reduce: pathogen transmission, healthcare-associated infections, and antibiotic resistance. II. Record review According to the Resident Census and Conditions form provided by the executive director (ED) on 9/26/22 at 11:00 a.m., the facility census at the time of the survey was 36 residents. The form documented there were four residents who were currently receiving antibiotics. The facility's last COVID-19 outbreak was 9/16/22. III. Staff interviews The director of nursing (DON) and the executive director (ED) were interviewed together on 10/4/22 at 9:01 a.m. The ED said the DON was the acting ICP since the assistant director of nursing (ADON) position had not been filled. The DON said she had just recently taken over the position of ICP and had not yet started the Centers for Disease Infection Preventionist training, but was planning to start in the near future. The facility had no qualified ICP at the time of the survey.

Jun 2021 5 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to respond to grievances for one (#3) of one out of 21 sample residents. Specifically, the facility failed to conduct a thorough investigation regarding a grievance filed by Resident #3. Findings include: I. Facility policy and procedures The Complaints and Grievances policy, effective 9/1/19, was provided by the social service director (SSD) on 6/24/21 at 2:30 p.m. The policy documented in part, Residents and their representatives, family members, or advocates have the right to make complaints or grievances without fear of reprisal or retribution from the community. The community's goal is to provide prompt investigation and resolution of all complaints and grievances; A grievance is a written complaint or verbal complaint that cannot be resolved promptly by the Executive Director or Administrator of the community. Additionally, the following circumstances constitute a grievance: -Whenever the resident, his/her representative, or family member requests that a complaint be handled as a formal grievance; -When a written response is requested from the community then it is managed as a grievance. All actions, investigations, and resolutions are documented on the complaint/grievance report form; The Executive Director/Administrator is responsible for the resolution of complaints and or grievance; the maintenance of all documentation, including the complaint grievance report form, follow-up actions/investigations, and updating the concern/grievance log with details concerning the resolution, and; The complaint/grievance officer provides oversight of the grievance process including, staying in periodic contact with the person who filed the grievance until the matter is investigated, and a plan is enacted for resolution. II. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the June 2021 computerized physician's orders (CPO) diagnoses included hypertensive heart disease, atrial fibrillation, muscle weakness, need for assistance with personal care and repeated falls. According to the 6/23/21 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She required extensive assistance of one person with bed mobility and toileting. She was mobile in a wheelchair. A.Resident interview The resident was interviewed on 6/21/21 at 5:00 p.m. She said that she felt the facility was short staffed at nighttime because she waited a long time for her call light to be answered. She gave an example of this and said that one night, not long ago, she rang her call light in the bathroom to be taken off the toilet. She said she waited so long that she got a ring around her bottom. She said she had reported it to the nurse and that it had not happened since. B. Record review A written grievance was provided by the SSD on 6/24/21at 11:45 a.m. The grievance form was dated 5/25/21. It documented in part that the resident reported to the SSD that she had been left on the toilet too long. There were no further details of when or what time this incident had happened. The summary section documented that the resident did not want to be left on the toilet too long. The resolution was that the resident stated that so far she had not been left on the toilet again and that she would notify the SSD if it happened again. The NHA signed the form on 5/26/21 and the form revealed the grievance was resolved with a date of 5/27/21. The form was also signed by the resident on the bottom. -There was no further documentation found on the form or in the resident's clinical record to demonstrate that an investigation was initiated to find out who was involved in the residents care the day in question when she was left on the toilet too long. The May 2021 resident council meeting revealed that Resident #3 was in attendance. The issue documented under nursing was that night time call lights were not being answered in a timely manner. -The minutes did not document the resident's additional comments of being left on the toilet too long. See SSD interview below. III. Staff interviews The SSD was interviewed on 6/24/21 at 1:56 p.m. She said that she was responsible for overseeing grievances. She said that she liked to handle residents' concerns right away if she could. She said if a concern was easily resolved she did not always complete a written grievance. She said that during the last resident council meeting Resident #3 brought up that she had been left on the toilet so long that she had a ring around her bottom. She said that a frequent visitor to the facility had attended the meeting and brought the resident ' concern to her attention and she filled out a grievance form and followed up. She said she did not think that an investigation was done and that she did not interview any staff. She said she followed up with the resident to make sure it did not happen again. She agreed the grievance was not completed thoroughly. The director of nursing (DON) and nursing home administrator (NHA) were interviewed on 6/24/21 at 3:20 p.m. The DON said that she had heard about the grievance and that it was brought up by a frequent visitor to the facility. She said she did not know what the follow-up was for the grievance. The NHA said that grievances were resolved as soon as possible and that it should be reviewed with the resident and that they agree with the resolution. She said she signed off on grievances once they were resolved. She said that she had not completed an investigation and that she probably could have checked with the CNAs (certified nurse aids) on all shifts.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to refer one (#2) of one out of 21 sample residents to the appropriate state-designated authority for level II preadmission screening and resident review (PASARR) evaluation and determination for services. Specifically, the facility failed to ensure the resident, with a known psychological disorder, was properly assessed on the PASSAR level I screen to gain and maintain her highest practicable, medical, emotional and psychosocial well-being. Findings include: I. Facility policy and procedure The Preadmission Screening Resident Review (PASARR) policy, effective [DATE] was provided by the social service director (SSD) on [DATE] at 4:53 p.m. The policy documented in part, Policy statement: .the purpose of a Level I screen is to identify individuals whose assessed needs require that they receive additional services for their intellectual disabilities or serious mental illness. Individuals who are determined to qualify at Level I are then evaluated more extensively in order to confirm the determination of an intellectual disability or mental illness for PASARR purposes. This is a Level II screen. This assessment may result in a set of recommendations for additional services that are to be included within the individual's person-centered plan of care. Policy guidelines: .a baseline person-centered plan of care will be developed and implemented within 48-hours based on the PASRR recommendations; Social service documentation should be completed in the medical record under the progress note section; All PASRR related materials and documents are retained in the resident medical record. II. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), unspecified dementia and schizoaffective disorder. According to the [DATE] minimum data set (MDS) assessment the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had moods to include trouble falling or staying asleep or sleeping too much and feeling tired or having little energy. She did not have any behaviors. According to the [DATE] admission MDS, the resident had no moods and no behaviors identified. She was coded as having a diagnosis of schizoaffective disorder. She was identified as not being evaluated for a PASRR level II. III. Resident interview The resident was interviewed on [DATE] at 10:30 a.m. She said that she had been through many difficulties and loss. She said she had recently lost her husband, her home, all her pets and had been living with her grandson. She said he put her in the facility and had ripped her off to include her car keys and her driver's license. She said she was told her grandson had power of attorney (POA) over her and she hollered and screamed at them (facility staff) that he was not her POA or caretaker. She said she had so many bills and she did not know what was going to happen to her or if she was going to be able to stay at the facility. She said she was in no condition to take care of herself and became tearful and said she knew she was supposed to be strong. She then shared that she had been a deep-sea scuba diver, had a black belt in karate and was an information technology specialist. She said unless someone had lived in her shoes; they would think she was crazy. IV. Record review A social service PASARR and discharge planning evaluation dated [DATE] documented that a pre-admission screening review was completed and a level II was not triggered. The resident's initial goal was to return to baseline and remain in the facility long term. An admission psychosocial review, dated [DATE], documented in part the resident was alert and oriented times three. She was responsible for herself and the section titled advance directives, establishment of living will/power of attorney/healthcare proxy, etc. was blank. Under the psychosocial column it was documented she liked to review all details of a problem and calmly think it over, she had an open mind and enjoyed change. She stated her spouse was abusive to her and her children and when people did not listen to her or called her a liar, it triggered her. Under the mental health section it documented she had not been hospitalized for a psychiatric reason and that she had a diagnosis of schizoaffective disorder. Under the communication strengths and additional comments section it was documented the resident enjoyed having someone to talk to. A physician visit progress note dated [DATE] identified under the impression and recommendations column that the resident had schizoaffective disorder. There was no additional documentation to show the resident's current medical treatment status related to this diagnosis. An additional, co-visit occurred on this date with a behavioral health practitioner. The note documented the following: Patient reported she was not happy because she could not talk about life at (name of long term care facility). She reported her partner shot himself in front of her and died, her daughter shot herself two years ago and died and her grandson, who claimed to be her POA hung himself and died. Reviewed healthy coping skills and the importance of self-care. Patient showed no signs of suicidal or homicidal ideation, plan or intent. Patient had difficulty tracking. -The note did not document what type of coping skills were reviewed with the resident. A care conference note dated [DATE] and attended by the resident, documented in part that she was alert, cognitively intact and had some anxiety. She was pleasant and easy to talk to. -There was no documentation found of any follow up to the physician visit, above in the electronic medical record (EMR). There was no documentation found in the social service section to demonstrate that the resident was regularly checked on to ask how she was adjusting to being in the facility or if she needed any additional emotional or psychosocial support. -There was no documentation found in the resident's EMR to demonstrate that a PASRR level I screen had been completed. Additional documentation found in the EMR revealed the resident had a diagnosis of schizoaffective disorder. On [DATE] (see below) the SSD printed out a copy of the PASARR level I screen that she submitted. The assessment listed three diagnoses: dementia, COPD exacerbation and respiratory failure with hypoxia. A PASARR level II was not required. -The Schizoaffective disorder was not listed as one of the diagnoses as indicated on the [DATE] CPO. -There was no resident centered care plan found to address her schizoaffective disorder. V. Staff interviews The SSD was interviewed on [DATE] at 10:27 a.m. She said that she was still learning about psychiatric medications and diagnosis. She said she knew that a level I had to be completed upon admission. She said she went directly into the the state web portal to complete Resident #2's PASRR level I but had not printed out a copy to place in her EMR. She said Resident #2 did not trigger a level II and that she did not have any behaviors. She said when talking with the resident since her arrival, she was very upset that her grandson was named her medical proxy and that her grandson did not have any authority over her. She said the resident was alert and oriented and able to make her own decisions. She said the resident did embellish her stories at times and that a couple of days ago the resident presented with some behaviors stating she was somewhere she was not. She said she did not always document everything that the resident talked to her about. She said she had not thought about recommending or offering the resident a psychosocial evaluation after hearing everything the resident had been through and shared with her since her admission. She said she would be submitting a PASARR level I update and she would be adding the schizoaffective diagnosis this time. She said she would reach out right away to the psychiatrist that oversees other residents at the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide services to meet professional standards of quality during medication preparation and administration. Specifically, the facility: -Failed to ensure proper hand hygiene was followed during medication administration; -Failed to ensure medications were not touched with bare hands; and, -Failed to ensure medications were not pre-poured. Findings include: I. Facility policy and procedure The Medication Administration policy, last revised January 2013, was provided by the director of nursing (DON) on 6/24/21 at 4:00 p.m. The policy documented in part, Facility staff should comply with facility policy, applicable law and the State Operations Manual when administering medication; Prior to preparing or administering medications, authorized and competent facility staff should follow the facility's infection control policy (e.g. handwashing); Facility staff should not touch the medication when opening a bottle or unit dose package. The Hand Washing policy, effective 10/1/17, was provided by the DON on 6/28/21 at 1:00 p.m. The policy documented in part, Proper hand washing/hand hygiene technique must be used at all times when indicated. Hand washing is the most important component for managing the spread of infection; Hand washing is performed: before starting work, when hands are visibly soiled or contaminated with blood or other body fluids, before and after each resident contact, before taking part in a medical procedure and after contact with a resident's intact skin. II. Observations and interviews Licensed practical nurse (LPN) #1 was observed on 6/22/21 at 4:00 p.m. during medication pass. She completed preparing medications for a resident in room [ROOM NUMBER] she then turned to a resident sitting next to her medication cart who was in distress and asking for help. She touched the resident's left arm and then moved her hand on the wheelchair handle. She did not sanitize her hands and then picked up the medication cup and took it to the resident in room [ROOM NUMBER]. Registered nurse (RN) #1 was observed on 6/23/21 at 8:38 p.m. during a medication pass. She said she was just about to prepare medications for a resident in room [ROOM NUMBER]. She opened the top drawer of her medication cart and she took one stool softener out of a paper medicine cup that had three, pre-poured stool softener pills in it with her bare hand. She then took another paper medicine cup with two white tablets which she identified as two Tylenol pills. She said she knew the resident received a stool softener and that she always gave her Tylenol at night because she knew she would be asking for some. RN #1 said she liked to pour the stool softeners that she was going to need because the stock bottle was big and bulky and it was hard to pour out one at a time. III. Administrative interview The DON was interviewed on 6/23/21 at 3:20 p.m. She said that nurses should sanitize their hands in between touching residents. She said that medications should not be touched with bare hands even if the nurse sanitized them beforehand. She said that medications should never be pre-poured.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure behavior monitoring was conducted for target behaviors related to the use of psychotropic medications for one (#13) of five residents reviewed for medications of 21 sample residents. Specifically, the facility failed to ensure: -Target behaviors were being tracked for the use of Abilify (an antipsychotic medication) for Resident #13; and, -A black box warning for the use of Abilify was included on the consent form for Resident #13. Findings include: I. Facility policy and procedure The Unnecessary Medications policy, originally dated 4/9/07 and most recently revised on 9/1/18, documented that the management of the drug/medication regimens of each resident was established to eliminate the administration of unnecessary medications. It documented antipsychotic medications were any drug that affects brain activates associated with mental process and behavior. It documented behavioral interventions were individualized non-pharmacological approaches to care that were provided as part of a supportive physical and psychosocial environment and were directed toward preventing, relieving and/or accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident's mental, physical or psychosocial well-being. It documented each resident's drug regimen would be free from unnecessary drugs. An unnecessary drug was defined as any drug used without adequate monitoring. It documented the goal of a resident's medication regiment was to keep the resident free from unnecessary drugs and included promoting and maintaining the resident's highest practicable mental, physical and psychosocial well-being, as well as considering and using non-pharmacological interventions when indicated, instead of, or in addition to, medication. It documented the facility's monitoring system included observation, assessment and reporting of the following: Symptoms suggesting the need for medication (including initiated or continued use of antipsychotic medication), the efficacy of medications and adverse consequences of medication and the identification and response to adverse consequences. II. Professional reference The [NAME] Nursing Drug Handbook 2020, page 87 documented a black box alert which stated, in pertinent part, Aririprazole (Abilify) had an increased risk of mortality in elderly patients. mainly due to pneumonia. III. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the June 2021 computerized physician orders (CPO), diagnosis included major depressive disorder, recurrent, unspecified; agoraphobia with panic disorder; other specified depressive episodes; other specified anxiety disorders; post-traumatic stress disorder, unspecified; restlessness and agitation. The minimum data set (MDS) assessment dated [DATE] documented that the resident scored 15 out of 15 for a brief interview for mental status (BIMS) assessment, which meant the resident was cognitively intact for daily decision making. It documented the resident's only symptom of a mood disorder was sleeping disturbance almost daily. It documented no psychosis, no concerning behaviors, no wandering or rejection of cares. It documented the resident received an antipsychotic medication, an antidepressant and an antianxiety medication on seven of seven days during this look-back period. It documented no GDR had been attempted for the use of Abilify for Resident #13. B. Record review 1. Care plan The care plan related to the use of antipsychotic medications, originally dated 5/16/17 and most recently updated on 4/27/21, documented Resident #13 was receiving antipsychotic medication for a major depressive disorder. Interventions included administering medications as ordered by the physician and monitoring for side effects, adverse reactions and effectiveness every shift. 2. Physician orders The June 2021 CPO documented Resident #13 was ordered, in pertinent part: -Aripiprazole (Abilify), 5 milligrams (mg) QD (every day). This antipsychotic medication was ordered on 8/12/2020 for major depressive disorder. 3. Consent for psychotropic medications The consent for Abilify was completed and signed by the resident on 2/25/21. However, there was no black box warning for the use of Abilify seen on this consent. 4. Behavior monitoring records The May and June 2021 behavior monitoring forms were reviewed in the resident's electronic chart. There were no behavior monitoring records seen for the use of Abilify. There were no target behaviors seen in the chart for the use of Abilify. 5. Progress notes The integrated progress notes were reviewed for May and June 2021. There were no integrated progress notes which addressed the use of Abilify for Resident #13. There were no notes that addressed target behaviors for the use of Abilify for Resident #13. 6. Physician notes The primary care physician (PCP) progress notes dated 4/27/21 documented long-standing anxiety and panic disorder with a history of multiple medication trials and failures. It documented, per a remote review of Resident #13's chart, facility staff reported Resident #13 had been doing a little bit better in terms of anxiety recently, as she had entertained visitors from outside in her room with the relaxation of Coronavirus-19 restrictions a few weeks prior. It documented that, in relation to the major depressive disorder with anxiety, the resident's mood was stable on the current medication regimen. It documented that the PCP would hold off on further weaning of medications until the PCP was able to have a face-to-face visit with the resident again. 7. Additional records The record review documented the latest nursing psychoactive medications quarterly evaluation completed was dated 7/28/2020. It failed to address Resident #13's use of Abilify. -There were no documented psychoactive medication evaluations which addressed the resident's Abilify since it was initially prescribed on 8/12/2020. -There were no psychotropic drug committee notes found in Resident #13's electronic record since the resident was initially prescribed Abilify. C. Staff interviews The nursing home administrator (NHA) was interviewed on 6/22/21 at 4:00 p.m. She said the facility's psychotropic drug committee had not been meeting due to COVID-19. She said this committee was scheduled to begin again sometime during the work week of 6/28/21 through 7/2/21. She said this committee used to be held on the second Friday of each month. The licensed practical nurse (LPN) was interviewed on 6/24/21 at 9:09 a.m. She said Resident #13 did not display any psychotic features as part of her major depression. She said the facility was not formally tracking target behaviors for the use of Abilify on a behavior monitoring sheet. She said they should be tracking behaviors for this medication because it was a big one. She said it was especially important to monitor the use of Abilify because this antipsychotic medication carried a black box warning. She said black box warnings should be documented on the consent forms. The director of nursing (DON) was interviewed on 6/24/21 at 1:59 p.m. She said the assistant director of nursing (ADON) had updated some resident behaviors on 6/22/21. She said she would check to see if he had added target behaviors for Resident #13's use of Abilify. The DON said there should be a black box warning on Resident #13's consent for Abilify and would check to see if someone put the black box warning on the back of the consent form. She said the facility should have been monitoring target behaviors for Resident #13's Abilify because it was being used for major depression. She said it was important to have separate behavior monitoring documentation for each psychotropic medication in order to determine which medication was working on which specific target behaviors. She said Resident #13 was first prescribed Abilify in August 2020 and the facility should have been monitoring specific target behaviors since that time. The DON said she had no idea why Resident #13's target behaviors for the use of Abilify were missed, but guessed it was probably because the resident had already been receiving an antidepressant medication for the same behavioral indicators. She said, unfortunately this was a different class of medications, which should have been on a separate behavior monitoring form. She said, if two different medications were prescribed for the exact same target behaviors, it was very difficult to determine which medication was effectively treating which target behavior. She said she would have combined both the antidepressant and the antipsychotic medication on the same behavior monitoring form. She said the facility had not been doing quarterly psychoactive medication evaluations since June or July 2020 because of COVID-19. She said that, coupled with a recent change in social services directors (SSD), contributed to these failures in monitoring target behaviors related to the use of psychotropic medications. She said the SSD was the staff that normally monitored resident behaviors and ensured behavior monitoring was being completed in a timely and accurate manner. She said the resident's care plan related to antipsychotic medication was updated by the floor nurse on 4/27/21. She said the floor nurse should have also caught this failure when she updated the care plan. The DON was interviewed on 6/24/21 at 2:59 p.m. She said the assistant director of nursing (ADON) failed to update Resident #13's behaviors on 6/22/21. She said she was unable to find a black box warning for the use of Abilify on Resident #13's consent form, either on the front or the back. She said there should have been a black box warning for the use of Abilify for Resident #13. The NHA was interviewed on 6/24/21 at 4:42 p.m. She said the facility should have had specific target behaviors being monitored for each and every psychotropic medication Resident #13 was ordered. She said the facility should have ensured there was a black box warning on the consent for Abilify before Resident #13 signed the consent form. The DON was interviewed on 6/24/21 at approximately 5:00 p.m. She said the facility's medical director had recently taken over Resident #13's case, so she felt that attention to this resident's psychotropic medications should be now handled much better than it had in the past.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observations, record review and interviews, the facility failed to ensure that all drugs and biologicals were properly stored in one of two medication carts. Specifically, the facility failed to ensure over the counter (OTC) medications were removed from circulation once they expired. Findings include: I. Facility policy and procedure The Medication Management Guidelines policy, effective 9/1/18, was provided by the director of nursing (DON) on 6/24/21 at 5:30 p.m. The policy documented in part, This policy provides guidelines for the administration of medications to residents per physician orders and according to applicable state/federal regulations and nursing standards of practice. Drug storage: No discontinued, outdated or deteriorated drugs are retained for use. All drugs are returned to the issuing pharmacy or destroyed in accordance with state regulations governing the destruction of medication. II. Observations On 6/23/21 at 10:49 a.m. the East medication cart was checked for expired medications. The following items were found: -Two bottles of aspirin 325 mg(milligram) coated, both with an expiration date of May 2021. One of the bottles had been opened and was in use. -One bottle of Systane eye drops expired August 2015 almost empty, with no name or date when opened. -One box of Coagu-Check PT (prothrombin time) test strips for determination of prothrombin time opened with an expiration date of 4/30/21. -Two, unopened packages of gluctose brand oral glucose gel. One with an expiration date of May 2021 and the second one with an expiration of February 2021. -One, unopened, unpackaged tube of gluctose brand gel with an expiration of February 2021. -One bottle of Loperamide 2 mg anti-diarrheal, opened, expired November 2020. -One opened package of cough drops with an expiration date of May 2021. III. Interviews Registered nurse (RN) #3 was interviewed on 6/23/21 at 8:00 a.m. She said that medications should be checked for the expiration date when taking it out of the cart to pour the medication. She said every nurse was responsible for checking the cart for expired medications and that they should be removed and placed in the medication room in the west hall for destruction. RN #3 said she would remove the expired medications right away. The DON was interviewed on 6/24/21 at 3:20 p.m. She said the nurses should be checking for expired and dated medications every time they are in the medication cart.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"What safeguards are in place to prevent abuse and neglect?"
"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

• No fines on record. Clean compliance history, better than most Colorado facilities.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 2 harm violation(s). Review inspection reports carefully.
• 43 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• Grade F (0/100). Below average facility with significant concerns.
• 60% turnover. Above average. Higher turnover means staff may not know residents' routines.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

Email me this report

About This Facility

What is Willow Tree's CMS Rating?

CMS assigns WILLOW TREE CARE 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 Willow Tree Staffed?

CMS rates WILLOW TREE CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 60%, which is 13 percentage points above the Colorado average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Willow Tree?

State health inspectors documented 43 deficiencies at WILLOW TREE CARE CENTER during 2021 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 40 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Willow Tree?

WILLOW TREE CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by STELLAR SENIOR LIVING, a chain that manages multiple nursing homes. With 80 certified beds and approximately 56 residents (about 70% occupancy), it is a smaller facility located in DELTA, Colorado.

How Does Willow Tree Compare to Other Colorado Nursing Homes?

Compared to the 100 nursing homes in Colorado, WILLOW TREE CARE CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Willow Tree?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the facility's high staff turnover rate.

Is Willow Tree Safe?

Based on CMS inspection data, WILLOW TREE CARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). 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 Willow Tree Stick Around?

Staff turnover at WILLOW TREE CARE CENTER is high. At 60%, the facility is 13 percentage points above the Colorado average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. 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 Willow Tree Ever Fined?

WILLOW TREE CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Willow Tree on Any Federal Watch List?

WILLOW TREE CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 80
Avg. Residents: 56
Occupancy: 70.6%
Ownership: For profit - Corporation
Chain: STELLAR SENIOR LIVING
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
1 Immediate Jeopardy citation: -12
2 Actual Harm citations: -10
43 Deficiencies: -10
Abuse Finding: -15
Final Score: 0/100

Nearby Alternatives

HORIZONS CARE CENTER 3-star PAONIA CARE AND REHABILITATION... 2-star

View all in DELTA →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 065249